Medicaid Redesign Initiatives Dan Heim Executive Vice President LeadingAge New York September 12, 2013 1 Agenda Medicaid Spending/Global Cap MRT Waiver Amendment FIDA Demonstration Balancing Incentive Program Supportive Housing Initiatives Other Major MRT Initiatives Shared Savings Opportunities Managed Care for the LTC Population Vital Access Providers/Safety Net 2 1
$10.0 $9.5 NYC Medicaid Long Term Care Spending (2003 2012) Projected Spending Absent MRT Initiatives * Aggregate Spending for all Programs (in Billions) $9.0 $8.5 $8.0 $7.5 $7.0 $6.5 2011 MRT Actions Implemented $980 million Estimated Savings $6.0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Years 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 # of Recipients 181,960 181,971 183,181 185,591 185,409 185,067 188,207 192,207 194,912 193,062 Cost per Recipient $34,438 $36,726 $38,933 $40,732 $42,700 $43,841 $43,867 $43,977 $43,363 $42,629 * Projected Spending Absent MRT Initiatives was derived by using the average annual growth rate between 2003 and 2010 of 4.4%. Accelerate MRT Initiatives MRT Budget Actions $24 million in Savings in SFY 2013-14 FIDA savings from Community DUAL eligible (Medicare/Medicaid) receiving > 120 days ($7 million in 13-14 growing to $28 million in 14-15) Accelerate MLTC enrollment ($3 million) Other Reforms/Savings other avoidable costs ($25 million) million in 14-15) Increase manual review of FFS claims ($8 million) Gold STAMP Program to reduce PUs ($6 million) Restore 2% ATB cut ($714 million gross in 14-15; $357 million state) Through managed care, reduce hospital readmissions, ER use and Accounts receivable recoveries ($50 million in 13-14 growing to $80 4 2
Medicaid Global Spending Cap The cap increased from $15.9 billion in SFY 2012-13 to $16.4 billion in 2013-14, roughly 3.2% (vs. the 3.9% increase in the CPI-Medical Services) State ops spending now included under the cap Local share growth takeover continues (2% limit) $730 million transferred from the global cap to the Mental Hygiene Stabilization Fund in SFY 2013-14, and $445 million in SFY 2014-15 Implications: Increased pressure on global cap 2% ATB cut remains in place for SFY 2013-14 Total spending through June was $7 million below projections 5 MRT Waiver Amendment NYS currently has a waiver amendment pending with CMS to reinvest $10 billion in MRT federal savings over 5 years State has argued the waiver is essential to implement the MRT action plan, prepare for ACA implementation and address underlying delivery system challenges: Lack of primary care; Weak health care safety net; Health disparities; and Transition challenges to managed care CMS has not yet acted on the waiver request 6 3
MRT Waiver Reinvestment Strategies Primary Care Expansion ($1.25 billion) Health Home Development ($525 million) New Care Models ($375 million) Expand Vital Access/Safety Net Program ($1.5 billion) Public Hospital Innovation ($1.5 billion) Medicaid Supportive Housing ($750 million) Long Term Transformation - Integration to Managed Care ($839.1 million) 7 7 MRT Waiver Reinvestment Strategies Capital Stabilization for Safety Net Hospitals ($1.7 billion) Hospital Transition ($520 million) Ensuring the Health Workforce Meets the Needs in the New Era of Health Care Reform ($500 million) Public Health Innovation ($395.3 million) Regional Health Planning ($25 million) MRT and Waiver Evaluation Program ($500 million) 8 8 4
Managed Care for the LTC Population MRT 90, Mandatory Enrollment in MLTC Plans: Expands MLTC for dual eligibles who need HCBS Benefits include home care, personal care, social supports, and transportation The costs of nursing home services are included in the capitation, providing a financial incentive for the plans to keep their members healthy and living in the community MLTC enrollment has steadily increased: than 100,000 currently; and Less than 2% of MLTC members are in nursing homes Enrollment has increased from approximately 10,000 in 2004 to more Number of MLTCs has grown from 16 plans to more than 40 plans 9 Managed Care for the LTC Population 10 5
Under the Fully Integrated Dual Advantage (FIDA) demonstration project: 170,000 dually eligible members (Medicaid and Medicare) in 8 downstate counties will be enrolled into full-integrated managed care products FIDA Demonstration A conversion in place approach to enrollment will be used to add a Medicare benefit to the MLTC plan that a dual is enrolled in through passive enrollment Members will be able to op-out of the Medicare managed care product at any time 11 Two Types of Plans: Primary FIDA Dual eligibles, age 21 and over that require community-based LTC services for more than 120 days who are not residents of an OMH facility or FIDA Demonstration receiving OPWDD services Geographic Service Area: Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk and Westchester Counties OPWDD FIDA Dual eligibles, age 21 and over, who are not residents of an OMH facility, and who are receiving services from the OPWDD system Geographic Service Area: Statewide 12 6
FIDA Demonstration Proposed Enrollment Process: April 2014 begin accepting voluntary enrollments for duals who need >120 days of community-based LTC services July 2014 begin process of passive enrollment notification for duals who need >120 days of community-based LTC services October 2014 begin accepting voluntary enrollment for duals that have exhausted Medicare benefits January 2015 begin passive enrollment notification for duals that have exhausted Medicare benefit in nursing homes Only applicable to full duals in the FIDA demonstration area who are not enrolled in PACE, MAP or I-SNP 13 Proposed Covered Benefits: FIDA Demonstration DOH is proposing to use the NY Medicaid definition of medical necessity for all services Covered services include services covered by the existing Medicare and Medicaid programs in New York in addition to home and community-based waiver services (e.g., LTHHCP) FIDA plans will have discretion to supplement covered services with non-covered services or items where so doing would address a participant s needs, as specified in the participant s person-centered service plan 14 7
Status and Next Steps: FIDA Demonstration CMS announced its approval of the memorandum of understanding with NYS on August 26, 2013 DOH is working with CMS on implementation funding for the first two years All FIDA plans must meet Medicare/Medicaid requirements, state procurement standards and insurance rules and pass a comprehensive joint CMS-state readiness review DOH and CMS must finalize the rate setting methodology and numerous operational details The state, each FIDA plan and CMS must execute a 3-way contract 15 Balancing Incentive Program BIP allows states to implement 3 structural components to rebalance state Medicaid LTC expenditures to at least 50% HCBS No Wrong Door/Single Entry Point Core Standardized Assessment (UAS-NY) Conflict Free Case Management The NYS BIP period is from 4/1/13 9/30/15. NYS receives additional 2% FMAP on HCBS LTSS ($599 million in total) BIP funds will be used, in part, to assure sufficient plans and provider options in less populated counties and for more difficult-to-serve members through transition rates to attract additional plans/providers 1 year funding of $20 million in state operations costs 16 8
Temporary rate adjustments for providers affected by closures, mergers, consolidations, restructurings or acquisitions Total VAP/SN Pool increased to $182 million in 2013-14 Includes reallocation of $30 million from the NH Financially Disadvantaged Program $51.6 million is committed to Round I projects Applications evaluated based on: (1) provider financial viability; (2) community service needs; (3) quality care improvements; and (4) health equity Round I: approved 13 projects totaling $69 million over 3 years Vital Access Providers/Safety Net 156 Round II applications totaling $1.1 billion not yet acted on CMS has not yet approved all state plan amendments Open application process but Round I and II projects may consume this year s funding 17 SFY 2013-14 budget includes $86 million to expand access to supportive housing services: Supportive Housing Initiatives Continues $70 million in MRT dollars to fund various supportive housing initiatives New funding of $12.5 million (when resources are available) Designates $4 million from Medicaid savings derived from the closure of hospital and nursing home beds Allocates $24 million for 7 pilot projects, including $3 million for LeadingAge NY s Senior Supportive Housing Pilot and $5 million for rapid transitions from nursing homes to independent living 18 9
Other Major MRT Initiatives Health Homes Behavioral Health Carve-In/HARP ACA Implementation Medicaid Administration Reform 19 A major opportunity under Medicaid redesign MRT is affecting the cost curve There is no commitment to trend factors Payments could be linked to both performance measures and ensuring safety net Options: Shared Savings Opportunities Global Shared Savings : State captures shared savings by lowering managed care payments as costs decline. State then directly pays providers or through managed care plans Managed Care Shared Savings : State requires plans to share savings with their provider networks through sub-capitation and/or performance bonus payments; may be tested in FIDA Other, less formal opportunities may emerge 20 10
For Further MRT Information MRT Website: http://www.health.ny.gov/health_care/medicaid/redesign/ Sign up for e-mail updates: http://www.health.ny.gov/health_care/medicaid/redesign/li stserv.htm Like the MRT on Facebook: http://www.facebook.com/newyorkmrt Follow the MRT on Twitter: @NewYorkMRT 21 Questions? 11