Redesign Medicaid in New York State

Balancing Incentive Program Webinar for Stakeholders

March 28, 2013

  • Document is also available in Portable Document Format (PDF)

Balancing Incentive Program

  • BIP provides states the option to implement three required structural components to improve access and availability of home and community–based services and rebalance the proportion of state Medicaid LTSS expenditures so that home and community based services comprise at least 50% in exchange for an additional 2% FMAP on HCBS LTSS.
  • The NYS BIP period is from Apr. 1, 2013 – September 30, 2015.

Required Structural Changes

  • No Wrong Door/Single Entry Point
    • Consistent information must be delivered about LTSS options whether an individual who is elderly, and/or physically, developmentally or behaviorally disabled (or their family member or representative) seeks information from a 1–800 number, a website or a local office that is part of the state’s NWD/SEP network. Assistance in enrolling the individual in services is expected.
    • NYS plans to expand NY Connects statewide, add an interactive screen to allow individuals to self–assess their LTSS needs prior to a comprehensive assessment, and develop tools and training to ensure consistent information about the LTSS available in communities across New York.
  • Core Standardized Assessment
    • UAS–NY
    • OPWDD undertaking a standardized assessment to capture data for their population based on the same assessment suite, interRAI
    • NYS will consider other assessments used for LTSS as part of its work plan activities
  • Conflict Free Case Management
    • There is separation of case management from direct services provision.
    • There is separation of eligibility determination from direct services provision: Eligibility is determined by an entity or organization that has no fiscal relationship to the individual.
    • Case managers do not establish funding levels for the individual: The case manager’s responsibility is to develop a plan of supports and services based on the individual’s assessed needs.
    • Individuals performing evaluations, assessments, and plans of care cannot be related by blood or marriage to the individual or any of the individual’s paid caregivers, financially responsible for the individual, or empowered to make financial or health–related decisions on behalf of the individual.
    • Where conflict exists, states must establish firewalls and appropriate safeguards that assure consumer choice and protect consumer rights. NYS will work to address any conflicts in its work plan.

Use of BIP Funds

  • Statute:
    • (c)(4) USE OF ADDITIONAL FUNDS. – The State agrees to use the additional Federal funds paid to the State as a result of this section only for purposes of providing new or expanded offerings of non–institutionally–based long–term services and supports described in subsection (f)(1)(B) under the State Medicaid program.

CMS Interpretation

  • CMS has developed a 3–part test to help States assess whether the use of enhanced FMAP meets legislative requirements. If a State can answer “Yes” to all 3 of the following questions, its proposed use of funds is acceptable.
    • Does the proposal increase offerings of or access to non–institutional LTSS?
    • Does the proposed expansion/enhancement of offerings/access benefit Medicaid recipients?
    • Is the proposal something that Medicaid funds can typically be spent on (i.e. the proposal does not involve a prohibited use of Medicaid funding)?

BIP in a Managed Care Environment

  • Biggest challenge may be CFCM;
  • NYS will work with other states to see how they have successfully mitigated any conflicts that arise in MC/MLTC environment;
  • BIP $ 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 and enhance consumer choice.

Status

  • BIP application approved by CMS 3/15/2013.
  • Detailed Work Plan due by September 1, 2013.
  • Additional FMAP commences April 1, 2013, the first full quarter after application is approved.
  • State must make progress toward identified targets and structural requirements in rebalancing activities to maintain additional aid.
  • BIP ends and state must have achieved the minimum proportion of 50% of state Medicaid LTSS expenditures on community based LTSS vs. institutional services by September 30, 2015.

State Specific Conditions

  • By April 1, 2013 submit revised Money Follows the Person Operating Protocol;
  • By April 15, 2013 submit revised Appendix C detailing specific dollar amounts and funding sources for activities under BIP, as well as a description of the gaps in NYS’s current system and how BIP and other initiatives will be used to address them;
  • By September 1, 2013 submit a comprehensive work plan describing how the state will meet rebalancing targets and structural requirements by September 30, 2015.
    • Particular focus should be devoted to aligning BIP and MFP infrastructure and ensuring that our conflict free case management strategies through managed care align with BIP requirements.

Questions?

Resources:

e–mail: BIP@health.ny.gov

URL for the manual: www.balancingincentiveprogram.org