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Maureen M. Corcoran, President Daphne K. Saneholtz, Senior Advisor

NYSACRA 2012 Leadership Conference Understanding New York’s Waivers November 29, 2012. Maureen M. Corcoran, President Daphne K. Saneholtz, Senior Advisor. Agenda. Health care context-NY & Federal Profiles of the individuals you serve Medicaid overview: Basics Case management

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Maureen M. Corcoran, President Daphne K. Saneholtz, Senior Advisor

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  1. NYSACRA 2012 Leadership Conference Understanding New York’s Waivers November 29, 2012 Maureen M. Corcoran, President Daphne K. Saneholtz, Senior Advisor

  2. Agenda • Health care context-NY & Federal • Profiles of the individuals you serve • Medicaid overview: • Basics • Case management • Managed care • NY Medicaid environment • Issues to consider • Tips for interfacing with state/fed policy makers

  3. Evolving Federal Context • On our way to 2014… • Supreme Court decision on ACA • Individual mandate upheld • Medicaid expansion optional • Impact of the presidential and congressional elections… ACA not repeal, but what challenges lie ahead? • Federal budget and deficit reduction • Fiscal cliff, slope, bump, excresence, etc. • “Entitlement reform”

  4. Evolving Context in New York • Optional Medicaid expansion • NY Partnership Plan (global 1115) inc. childless adults <100% FPL • NY est. to save 7% relative to without expansion • Financial negotiations related to NY 1115s and ICF/DD rates • Aggressive & Comprehensive MRT Action Plan • Health benefit exchange • Oct. 26, 2012 NY submitted its Blueprint application; state based health benefit exchange. Certifications expected by Jan. 1, 2013 • Oct. 1, 2012 NY submitted EHB Benchmark plan; largest small group plan, Oxford EPO + supplementation in certain areas of the state • Implications of Federal budget and deficit reduction 4

  5. Economic & Political Significance Of Medicaid to NYS • NYS #1 in overall Medicaid spending (2010) • Total spent $52B • 13.4% of the nation’s spending on Medicaid • NYS has 6.2% of the nation’s population • NYS spends 15.9% of all Medicaid expenditures on HCBS/ICFDD services • $246 annually for each citizen of NYS on IDD/HCBS services

  6. A Balanced Approach to ACA ImplementationPer Alan Weil, Executive Director, NASHP Delivery System Improvement Insurance Exchanges Provider Capacity Eligibility Systems

  7. CMS Perspective • “Stampede” to managed care • “Overwhelming” use of 1115 and some 1915(b) waivers • Dual planning grants • Health homes • CMMI (ACA §3021) • Payment reform is the goal

  8. Additional Health Care Context • Continuing trend toward home and community services, away from institutional care • DOJ/ADA/Olmstead – Federal investigations/ enforcement of state compliance with community integration mandates. Also IMD settlements. • New CMS proposed regulation on community integration…prohibition on HCBS in licensed homes • Continuing evolution/application of • Managed care/PCCM type models • Models of Care and Integration • Payment Reform: P4P, Value Based Purchasing; away from FFS

  9. Additional Health Care Context • Which means… • Lessening of the “silos”

  10. LA Integrated Permanent Supportive Housing Integrated Housing > 2300 units State level partnerships 10% of LITC 5% set aside/new rental S+C subsidies & Sec 8 PBV • People w/ MH/SUD • Frail elders • Youth aging out of FC • Very low income & need supports 24% decrease in Medicaid costs

  11. Which means… Lessening of the “silos” Continuing diffusion of system level interventions Maturing/adaptation of managed care tools & approaches Continuing emphasis on the care and relationships Care models include both specialty and physical Payment reform…movement away from FFS Additional Health Care Context

  12. Profiles of those you serve 12 Not just adults with IDD Not just residential options, also community support services, housing, day activities/supported employment Also, kids and other adults But let’s focus on adults < 65 y.o. with IDD

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  14. Medicare Medicaid Eligible Individuals • ~ 9 Million Americans are Medicare-Medicaid Eligibles (MMEs) • Dual eligible individuals are: MEDICARE MEDICAID % people 21% 15% % cost 36% 39% Let’s look at MMEs w/ IDD…those with IDD will be heavily influenced by state policy

  15. Mass. Medicaid Policy Analysis MMEs Breslin Davidson & T.Dreyfus. “Dual Eligibles in Massachusetts: A Profile of Health Care Services & Spending for Non Elderly Adults Enrolled in Both Medicare and Medicaid. Sept. 2011. MMPI

  16. 6% of MMEs 21-64 yo w/ IDD 6%

  17. 15% OF All Spending for MMEs 21-64 yo w/ IDD 6% = 15% OF $$

  18. 22% Inpatient + 43% Other Non-LTSS Spending

  19. Medicaid % of Expenditures: 50-72%

  20. Medicaid Fundamentals Basics Federally required services Waivers Core principles of Medicaid & what can be waived Types of waivers & what they are used for Medicaid managed care Managed care design considerations for states Case management & various types of authorities 21

  21. Medicaid Basics • Joint federal/state program; in NY, feds pay 50%, state pays 50% • Approx. 5.2 million New Yorkers enrolled in Medicaid; • 24% aged and disabled, • 37% non aged/disabled adults • 38% children (FY09)* • Unless CMS gives a waiver, Medicaid must: • Be statewide and uniform • Ensure access to services • Ensure recipients have free choice of provider *Kaiser statehealthfacts.org

  22. Medicaid Services & Coverage • State Plan: Medically necessary services • E.g., physical health, community mental health (AKA “card services”) • Delivery: Fee-for-service or managed care • Can use “carve outs” or specialty delivery systems • Waivers: • 1915(c) require an institutional LOC • 1115 • 1915(b) used to create managed care systems • Case management authorities

  23. What is a waiver? • Sections 1115 and 1915 of the SSA define specific circumstances in which the federal government may, at a state’s request, waive certain provisions of law. • If approved, a waiver is an agreement between the state and federal governments that exempts the State from certain provisions of Federal law. • Includes terms and conditions that define the strict circumstances under which and for whom the state is exempt from federal laws. • Once approved by CMS, it becomes an official document that outlines a portion of the State’s Medicaid program.

  24. Core Principles of Medicaid §1902 of the SSA *Social Security Act §1902(a)(3).  42 CFR 431.220 • Statewideness & Comparability • Single State Medicaid Agency • Freedom of Choice of Provider (per quals. est. by the State) • Individual’s right to a fair hearing* Waive-able w/ authority NOT waive-able Waive-able, but not with 1915(c) A key component of managed care NEVER waive-able

  25. See handout Medicaid Waiver Authorities 1915 (b) 1915 (c) 1915 (b)(c) 1115 Also 1915(a) – not a waiver, but… Waiver Types & Authorities

  26. What is Medicaid Managed Care? • State contracts with an organization to provide services to Medicaid consumers through a defined network of providers. • Can be… • Risk-based, • Noncomprehensive prepaid health plans (PHPs) or • Primary care case management (PCCM) • Various authorities* depending on type of managed care program design the state intends. *See detailed description of managed care authorities. VHCA website, “Resources” tab, Feb.17, 2012 www.vorysHCAdvisors.com

  27. Managed Care Considerations for States • Geography • Population-target group, type of needs/services • Voluntary or mandatory • Network of providers • Choice of plans • Carve outs of certain services or groups of services • Waivers frequently used: Statewideness, Comparability of services, Freedom of Choice

  28. “Stampede” to Managed Care • It creates predictability for state Medicaid entities • Issues: Franchise permit fee, actuarial soundness, EPSDT • Funding disparities among populations-what happens with managed care? • BUT the ACA did not mandate managed care • Focus on the design & implementation of care management

  29. Several managed care programs, vehicles 1115 Waivers – Partnership Plan, F-SHRP Managed Long Term Care (1915(a)) FIDA, OPWDD FIDA People First Waiver- 1115 or 1915 b/c ?? Incorporate some of existing (c) Also ICF-MR rates, existing 1915(c) waivers New York’s Medicaid/Waiver Strategy

  30. NY’s 1915(c) Waivers

  31. New York’s 1115 People First Waiver

  32. DISCO will develop to providing full range of services inc. self directed, LTSS & acute health care. Integration Comprehensive care coordination and better integration of health & LTSS. Case management DISCO-non profit entity w/ experience working with individuals with IDD. Intent: risk bearing entities, regulated under insurance law. Procurement.Risk/Reserves, etc. Regulation of managed care plans Choice of DISCOs or DISCO/self directed option. Choice DISCO: provider as the plan. Provider/Conflict of Interest Provider Based Models of Care-ACOs, PACOs, Health Homes Financing-inc. “safety net” pool of funds $$$$$ Elements of PFW & Potential Questions

  33. MMEs are getting significant attention Remember the significant % of MMEs among those you serve. This policy will drive, could overtake, other policy/system efforts. MMEs must navigate both systems: complex processes, regulatory conflicts and incentives to cost shift Congress created in the ACA the Medicare-Medicaid Coordination Office within CMS…programs work together more effectively In April 2011, the CMMI launched a project State Demonstrations to Integrate Care for Dual Eligible Individuals.  Along with 14 other states, NYS was awarded planning grants to design person-centered approaches to better coordinate care for Medicare-Medicaid enrollees.  Medicare-Medicaid Eligible Individuals

  34. Where are DD Medicaid Consumers? • Partnership Plan (“global” 1115 waiver) • Physical health care; LTC = FFS • Largely does not include DD population • MLTC • LTC only; physical health care = FFS • Not statewide • Includes only a portion of DD population

  35. Where are DD Medicaid Consumers? • FIDA • Medicare Parts A, B, and D + all Medicaid state plan svcs + HCBS + supplemental svcs • Excludes DD MMEs • 123,000+ MMEs • Not statewide • OPWDD FIDA • Medicare Parts A, B, and D + all Medicaid state plan svcs + HCBS + supplemental svcs • Up to 10,000 DD MMEs • Statewide

  36. Where are DD Medicaid Consumers? People 1stAs an 1115 • Medicaid-enrolled and eligible for OPWDD svcs: • HCBS and CAH waiver-enrolled (66,000) • Receiving state plan svcs (31,500) • Non-OPWDD residential populations • OMH psych centers (82) • OMH RTFs (74) • SNFs (1,900) • OMH community residences (81) • Optional enrollment at statewide transition for certain populations who currently receive care coordination from an entity other than OPWDD (i.e., on other HCBS waivers)

  37. So… So… 66,000 from OPWDD HCBS and CAH waivers + 31,500 receiving state plan services 97,500 mandatorily enrolled at pilot phase

  38. Where are DD Medicaid Consumers? People 1stAs a 1915(b)/(c) • Qualifying DD + ICF-DD LOC + Medicaid-enrolled • Includes MMEs • This means individuals now receiving: • OPWDD 1915(c) waiver services • ICF-DD services • OPWDD TCM (MSC) • Other LTSS under the auspices of state agencies other than OPWDD (e.g., personal care) • Not (for pilot phase): • People receiving OPWDD state operated residential and day services • People who meet the above qualifications and live in a SNF, OASAS or OMH facility, or private psych hospital

  39. What is Case Management? Elements of Targeted Case Management • Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social, or other service. • Development and periodic revision of a specific care plan that is based on the information collected through the assessment. • Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services. • Monitoring and follow up activities. 

  40. Case Management Authorities See detailed description of each. VHCA website, “Resources” tab, Feb.17, 2012 www.vorysHCAdvisors.com Case Management provided in accordance with the administration of a waiver Administrative Case Management As a “service”, Targeted case management (TCM) Case management “embedded” in a rehab service available under the state plan Case management “embedded” as a federal requirement within EPSDT Case Management provided under 1915(i) Affordable Care Act §2703 Health Home

  41. The Next Time We Meet • Remember I said “BUT the ACA did not mandate managed care.” We need to focus on the design & implementation of care management. “Coordinated care” equation. • Continuing evolution/application of • Managed care/PCCM type models • Models of care and integration of specialty/physical • Payment Reform: P4P, Value Based Purchasing; away from FFS. Reimbursement related to outcomes. • Learning collaboratives and quality improvement

  42. Tips for interfacing with the Medicaid SSA & Other State Authorities Providers should: • Understand the rules of Medicaid • Understand the importance of your state plan, including mandatory and optional services, for whom, etc. • Remember that EPSDT is always mandatory for < 21yo • Understand the “specialty” services that are paid for by Medicaid; understand the interface with the related state plan and/or waivers • Some states have their complete state plans online. • Most waivers are online @ CMS website

  43. Tips: Interfacing and Advocacy (continued) • Understand whether services, limitations, reimbursement methodologies, and eligibility policies in your state are accurately/legally defined in the state plan AND whether they harmonize with your state laws and administrative rules. • Understand how the state plan amendment (SPA) process works, at the state and federal levels. • Determine how best to give input/be involved in this process. • With managed care, understand the rate setting process, including determination of capitation rates and what is in the capitation rates.

  44. We always hope for the easy fix: the one simple change that will erase a problem in a stroke. But few things in this life work this way, instead, success requires making a hundred small steps go right--one after the other…everyone pitching in…Atul Gawande

  45. About Vorys Health Care Advisors Maureen Corcoran, MSN, MBA 614.464.5461 | MMCorcoran@VorysHCAdvisors.com Daphne K. Saneholtz, JD 614.464.5461 | DKSaneholtz@VorysHCAdvisors.com Vorys Health Care Advisors 52 E. Gay Street, Columbus, OH 614.464.5461 | www.VorysHCAdvisors.com Vorys Health Care Advisors, LLC helps health care providers, business decision makers and professional associationsto achieve their objectives in a constantly changing governmental and business health care environment and to assist them in making well informed, strategic and tactical decisions tailored to their individual goals, needs and aspirations. Contact Information 47

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