Demonstration Proposal to Integrate Care for Dual Eligible Individuals

  • Presentation also available in Portable Document Format (PDF, 177KB)

March 13, 2012
1:00-2:30 PM

March 15, 2012
9:30-11:00 AM

Demonstration Proposal to Integrate Care for Dual Eligible Individuals

  • In March 2011, NYSDOH received a planning grant from CMS to develop a demonstration proposal around integrated care for individuals eligible for Medicaid and Medicare (Dual Eligibles)
    • CMS provided $1 Million
    • NYSDOH had 12 months to Develop and Submit a Proposal
  • Today´s presentation is an overview of the demonstration proposal that is being developed and will be available for public comment.

Important Dates

  • March 22, 2012 - Publish draft demonstration proposal for public comment
  • April 20, 2012 - Public Comment period will close
  • April 26, 2012 - Submit draft demonstration proposal to CMS
  • May 4, 2012 - CMS will publish draft demonstration proposal in the Federal Register for public comment
  • June 4, 2012 - Public Comment period will close
  • June 2012-September 2012 - Negotiations with CMS
  • September 2012 - Implementation begins
  • Fall 2013 - Enrollment Begins
  • January 2014 - Service Delivery Begins

Context of Demonstration in Care Management for All

  • Mandatory Managed Long Term Care enrollment of dual eligibles who receive community-based LTSS beginning this July 2012
  • Enrollment Plan anticipates eventual enrollment of all dual eligibles into MLTCP (Phase 6)

Proposed Care Model

  • Fully-Integrated Dual Advantage program
    • Capitated managed care program that provides comprehensive array of Medicare, Medicaid, and supplemental services - including:
      • All physical healthcare
      • All LTSS services currently available through MAP program
      • Additional services currently only available through HCBS Waivers
      • Additional supplemental services not currently required in NYSDOH managed care plans
      • All behavioral healthcare

Proposed Service Area

  • 8 Counties
    • Bronx
    • Kings
    • Nassau
    • New York
    • Queens
    • Richmond
    • Suffolk
    • Westchester

Proposed Target Population

  • All Full Dual Eligibles in 8 County Service Area
    • Age 21 and Over
    • Not receiving services through OPWDD
    • Not receiving services in an OMH Facility
    • Not participating in Bronx Health Access Network Pioneer ACO

Proposed Start Date

  • Phase 1 - January 2014
    • Those full dual eligibles in the service area who are enrolled in MLTCP who are receiving community- based long-term supports and services
  • Phase 2 - January 2015
    • All remaining full dual eligibles in the service area

Proposed Enrollment Process

  • Phase 1 - January 2014
    • In Fall of 2013, the independent Enrollment Broker will contact full dual MLTCP recipients of community-based care and inform them of intention to enroll them into the Fully-Integrated Duals Advantage Program
      • Dual eligibles will be informed that they will be enrolled into a FIDA plan offered by their MLTCP plan sponsor, if available, or will be contacted to be counseled through a choice of FIDA plan
  • Phase 2 - January 2015
    • In Fall of 2014, the independent Enrollment Broker will contact remaining full dual eligibles and inform them of intention to enroll them into the Fully-Integrated Duals Advantage Program
      • Dual eligibles will be informed that they will be enrolled into a FIDA plan offered by their Medicaid Advantage or Medicaid Advantage plan or will be contacted to be counseled through a choice of FIDA plan

Proposed Covered Services

  • Comprehensive Benefit Package
    • Includes:
      • All Medicare PH, BH, and Rx services and All Medicaid PH, BH, and LTSS State Plan Services
        • As outlined in Medicaid Advantage Plus
      • Plus most of the HCBS Waiver services presently available under NHTD, LTHHCP, and TBI Waivers
      • Plus Supplemental Benefits

Additional Covered Services (Beyond MAP coverage)

AIDS Adult Day Health Care
Assertive Community Treatment (ACT)
Assisted Living Program
Assistive Technology
Case Management for Seriously and
Persistently Mentally Ill
Community Transitional Services
Comprehensive Medicaid Case
Management
Consumer Directed Personal
Assistance Services
Continuing Day Treatment
Day Treatment
Family-Based Treatment
Health and Wellness Education
HIV COBRA Case Management
Home and Community Support
Home Visits by Medical Personnel		 Independent Living Skills and Training
Intensive Psychiatric Rehabilitation
Treatment Programs
Medicaid Pharmacy Benefits-per State
Law
Moving Assistance
OMH Licensed Crs∗
Partial Hospitalizations
Personalized Recovery Oriented
Services
Positive Behavioral Interventions and
Support
Social Day Care Transportation
Structured Day Program
Substance Abuse Program
Telehealth
Wellness Counseling

Proposed Care Coordination Model

  • Participant-Centered
  • Interdisciplinary Care Coordination Team
    • Includes
      • Participant,
      • Designee,
      • Primary Care Physician,
      • Care Coordinator, and
      • any other providers
        • as chosen by Participant or
        • as recommended by PCP or Care Coordinator and agreed to by Participant

Proposed Beneficiary Protections

  • Independent Enrollment Broker
  • Independent Participant Ombudsman
  • Integrated Grievances and Appeals Processes
  • Choice of Plans
  • Choice of Providers
  • Maximum travel, distance, wait, and appointment times
  • Continuity of Care
  • Single Consolidated Statement of all Rights and Responsibilities
  • No Costs (except Part D co-pays for non-LTSS participants)

Proposed Stakeholder Process

  • Input Welcome
  • During Public Comment Period
    • Webinars
    • Public Meetings
    • Submission of Public Comments
  • June 2012 through December 2013
    • Quarterly Meetings
    • Materials on website
    • Outreach and Education Campaign
  • During Implementation
    • Annual Quality Surveys
    • Participant Advisory Committees
    • Participant Feedback Sessions
    • Stakeholder Quarterly Meetings

Assistance Needed

  • Stakeholders PLEASE:
    • Provide Pre-Proposal Input
    • Share the Draft Proposal with Your Networks
    • Submit Comments on the Draft Proposal
    • Encourage Others to Submit Comments
    • Provide Letters of Support

Questions or Comments?

  • Please submit questions and comments through the Webex feature
  • Questions and Answers will be summarized and posted on the MRT website

Can always submit information/questions/comments to: mltcworkgroup@health.ny.gov