Managed Long-Term Care Understanding the Changes to Medicaid Home Care in New York State

1. Managed Long-Term Care Understanding the Changes to Medicaid Home Care in New York State Evelyn Frank Legal Resources Program David Silva, Ass’t. Director & Valerie Bogart, Director (212) 971-7658 legal@selfhelp.net http://nyhealthaccess.org

2. What is Managed Long Term Care? 2

3. What is Medicaid Managed Long-Term Care? Medicaid Managed (Care) Long-Term Care • The public health insurance program for the poor, operated by the State • A type of private health insurance company paid a fixed amount per capita to authorize and pay for all covered services (“capitation”) • Home care • Adult day care • Physical therapy • Nursing home • Etc. 3

4. We’ve been here before Original Medicare Remember when there wasonly ONE Medicare?

5. Why are we talking about this? • The privatization of Medicaid home care in New York state due to Medicaid Redesign. Old System New System

6. Old System 6

7. New System 7

8. So what? • New bureaucracy • No more CASA staff (mixed blessing) • Less accountability (if that’s even possible) • New incentives • Fixed payment (“capitation”) per person per month creates financial incentive to contain costs • New service delivery system • Providers of long-term care services must contract with private plans, not government agency 8

9. Managed Care vs. Fee for Service • The government wants to end Fee-for-Service in both Medicaid and Medicare. • FEE FOR SERVICE – like American Express card • Original Medicare or regular Medicaid • Client uses any provider that accepts Medicare or Medicaid – not limited to any network • Provider bills insurance (Medicare or Medicaid) directly • Some services require “prior approval” but many don’t – if doctor prescribes, insurance pays • MANAGED CARE – like having a MACY’s card only • Medicare Advantage or mainstream Medicaid Managed Care • Providers must be in-network, services & specialist referrals must be approved by a Primary Care Provider (PCP) • Provider bills managed care company, not Medicare or Medicaid. If client went out of network, provider may not get paid

10. What changed? 10

11. MLTC will be mandatory • Over the next year, all recipients of Medicaid home care services will be required to enroll in MLTC plans • Only affects dual eligibles (Medicare and Medicaid) • Mandatory enrollment will be phased in gradually from July 2012 through 2013, starting with NYC home attendant cases • Clients have 60 days from date of notice to select an MLTC plan or one will be chosen for them at random

12. Affected Clients • Dual eligibles (must have Medicare & Medicaid); and • Age 21 or older; and • Receiving Community-Based Long-Term Care services for >120 days in a calendar year • Personal care (PCA/home attendant) • Certified Home Health Aide (CHHA) • Adult Day Care • Lombardi Waiver (Long-Term Home Health Care Services) • Private-Duty Nursing • Consumer-Directed Personal Assistance Program (CDPAP) 12

13. What will happen to them? • These individuals will be required to join a Managed Long-Term Care plan to receive their Medicaid home care benefits • Clients will receive notices from NY Medicaid Choice stating that they must select a plan or they will be randomly assigned to one • Clients will be given a list of plans from which to choose, which include: • MLTC plans (aka “partial-cap”) • Programs of All-inclusive Care for the Elderly (PACEs) • Medicaid Advantage Plus (MAP) 13

14. Personal Care carve-in Might have to change doctors/hospitals! Dental, vision, hearing, etc. Map of Managed Care Medicare Medicaid Medicaid Advantage Mainstream MMC Medicare Advantage Home Care Services PACE Partial-Cap MLTC MAP

15. Client plan options MLTC * Duals receiving CBLTC MAP PACE * Client will be assigned to MLTC if no selection made. 15

16. Two general types of MLTC plans in NYS • Most managed long term care plans are “partially-capitated” – the benefit package is solely Medicaid-only long-term care services and limited other health services – not all primary care. List follows. • “Full Capitation” – includes all Medicaid AND Medicare services – primary care, acute, hospital, behavioral and long term care services in the benefit package. This means the client might have to change all their doctors/hospitals! • Program of All-Inclusive Care for the Elderly (PACE) • Medicaid Advantage Plus (MAP)

17. Current EnrollmentPartial-cap MLTC Plans NYC 5-2012

18. Services authorized by MLTC • Home care: • Personal Care (home attendant) • Consumer-Directed Personal Assistance Program (CDPAP) • Home Health Aide, PT, OT (CHHA Personal Care) • Adult day care, PERS, home-delivered meals • Medical equipment, supplies, prostheses, orthotics, hearing aids, eyeglasses, respiratory therapy • Home modifications • Podiatry, Audiology, Dental, Optometry • Non-emergency medical transportation • Nursing home Above are partial capitation only. PACE, MAPlus include more primary and acute medical services

19. Letters from NY Medicaid Choice • Pre-notice 6/2012 to some Manhattan residents – “MLTC coming” - copy attached • First Notice – Enrollment Packet • Notice stating that individual must enroll in an MLTC plan within 60 days or they will be randomly auto-assigned. Includes a list of plans and educational material. • Second Notice • 30 days after 1st notice • Third Notice • 45 days after 1st notice; includes name of plan to which individual will be auto-assigned • Fourth Notice • 60 days after 1st notice; informing individual of auto-assignment

20. When? NY Medicaid Choice sends first letters to Manhattan PCA recipients Manhattan non-responders will be auto-enrolled. Begin sending letters to Bronx PCA recipients. Letters go to Brooklyn PCA recipients Letters go to Queens and Staten Island PCA recipients Letters to Lombardi, CHHA, adult day, LPN Q & SI: 60 days Kings: 60 days Bronx: 60 days NY: 60 days July August September October November December January2013 20

21. What about CHHA & Lombardi in NYC? • Only “long-term” CHHA clients are required to enroll in MLTC • Short-term clients can continue to receive CHHA services fee-for-service • Once a client enrolls in an MLTC plan, if they require HHA, PT, OT, visiting nurse, etc. it must be provided by their MLTC plan (under contract with a LHCSA) • Long-term CHHA clients won’t receive auto-enrollment letters until January 2013 at the earliest • Lombardi – will be auto-enrolled in NYC in Jan. 2013 or later • Adult day and private duty nursing – also Jan. 2013 or later

22. Implementation outside NYC DOH, “Mandatory Managed Long Term Care Enrollment Plan” posted athttp://www.health.ny.gov/health_care/medicaid/redesign/docs/2012-02-26_mltc_enrollment_plan.pdf • Phase II • Nassau, Suffolk and Westchester Counties – Anticipated January 2013 • Phase III • Rockland and Orange Counties – Anticipated June 2013 • Phase IV • Albany, Erie, Onondaga and Monroe Counties – Anticipated December 2013. • Phase V • Other counties with capacity – Anticipated June 2014. 22

23. Implementation Schedule DOH, “Mandatory Managed Long Term Care Enrollment Plan” posted athttp://www.health.ny.gov/health_care/medicaid/redesign/docs/2012-02-26_mltc_enrollment_plan.pdf • Phase VI • Previously excluded dual eligible groups contingent upon development of appropriate programs: • Nursing Home Transition and Diversion waiver participants; • Traumatic Brain Injury waiver participants; • Nursing home residents; • Assisted Living Program participants; • Dual eligibles that do not require community based long term care services. 23

24. Transition • Law requires MLTC plan to provide previous level of services for 30 days pending its new assessment • After the 30 days, State will allow plans to reduce services • Must give written notice and right to a hearing – but not AID CONTINUING beyond end of prior authorization period • Advocates think this violates the Due Process clause of the U.S. Constitution. 24

25. Advocacy Concerns

26. Advocacy Concerns See more info at http://wnylc.com/health/entry/114/ • Meeting Needs of High Hour Clients. • Capitation Incentive to Give Low hours – Many MLTC plans in NYC have done heavy marketing to enroll large numbers of low-hour clients. They receive same capitation rate for all clients. • High-need MLTC client can’t transfer to Personal Care/home attendant program. Now, MLTC will be mandatory – will have to fight plan for more hours. Standards for 24-hour care unclear.

27. Advocacy Concerns con’d See http://wnylc.com/health/entry/114/ & http://wnylc.com/health/entry/7/ • Consumer appeals/ fair hearings – rights not as clear as in personal care/home attendant program. • Standards for authorizing care – will MLTC plans be required to follow rules established through litigation, i.e., • can’t use task-based-assessment when client has 24-hour needs (“Mayer-III”) • must provide adequate hours to ensure safe performance of ADLs (NYS DOH GIS 03 MA/003 • non-self-directing people eligible if someone can direct care who need not live with them (92-ADM-49)(Illegal “Back-up” requirement). • Cannot terminate services when hospitalized

28. Advocacy Concerns Excess Nursing Home Usage MLTC benefit package includes nursing home care Wide variation among MLTC plans in rate of NH admission People with high-hour needs, or who are difficult to serve due to dementia, etc. are at risk of NH placement Reporting and State Oversight With budget cuts, does DOH have staff to monitor plans adequately, collect and analyze data on quality and monitor avoidable institutionalization? Plans must be required to monitor and report outcomes, quality measures, nursing home placement and

29. Advocacy Concerns Case Management – will it be more than limiting hours? Will it actually coordinate medical care, ensure access to transportation, other MLTC services? Disability literacy – understanding needs of people with disabilities, eg. Wheelchair fitting & authorization, “dignity of risk”. Capacity – Plans now have 37,000 members, will more than double their enrollment from July – Dec. 2012. Can they do it? Medicaid applications and recerts – role of CASAs? How ensure home care not disrupted when glitches in recertifications? See more in advocates letter to DOH, 5/2011* http://www.health.ny.gov/health_care/managed_care/appextension/ (under Public Comments)

30. Advocacy concerns - CDPAP Consumer Directed Personal Assistance Program – 2012 state budget requires all MLTC and Medicaid Advantage Plus plans to offer this option. Until now, only one MLTC plan has voluntarily offered CDPAP (ICS in NYC) CDPAP has inherent conflict with “managed care” – as it is not a medical model. Unclear whether MLTC plans, which are inherently medical/nursing model, will understand CDPAP and honor consumer choices See more concerns in advocates letter to DOH 05/2011, 3/12 and 12/11 See more on CDPAP at http://wnylc.com/health/entry/40/

31. The End Check out http://nyhealthaccess.org for updates! 31