Redesign Medicaid in New York State

Balancing Incentive Program
Work Plan Update

Mark Kissinger
Director, Division of Long Term Care

January 9, 2014

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

Balancing Incentive Program Background

The Balancing Incentive Program (BIP) is a funding opportunity offered under section 10202 of the Affordable Care Act:

  • Provides enhanced FMAP (+2%) to participating states to rebalance Medicaid Long Term Services and Supports (LTSS) by increasing access and expanding community services as an alternative to institutional care.
  • Requires 3 structural changes:
    • No Wrong Door/Single Entry Point network (NWD/SEP)
    • Core Standardized Assessment Instruments
    • Conflict Free Case Management

Balancing Incentive Program Overview

BIP involves:

  • rebalancing the delivery of long term services and supports (LTSS) towards community–based care;
  • promoting enhanced consumer choice;
  • standardizing information for eligibility determination and enrollment processes;
  • improving access to and expanding community LTSS; and
  • providing essential services in the least restrictive setting.
  • The BIP period is April 1, 2013 – September 30, 2015.
  • The State must make progress toward identified targets in the structural requirements and rebalancing goals to maintain additional aid.
  • When BIP ends, the State must show an increase in the community–based LTSS percentage from the baseline percentage by the end of the BIP period.

Balancing Incentive Program Structural Change 1

No Wrong Door/Single Entry Point (NWD/SEP) Network:

  • Consistent information must be delivered about LTSS options whether an individual seeks information from a 1–800 number, a website, or a local office that is part of the state’s NWD/SEP network.
  • Provides assistance in enrolling the individual in services.
  • The State plans to:
    • expand NY Connects statewide;
    • add an interactive web–based screening tool to allow individuals to help identify their LTSS needs; and
    • develop tools and training to ensure consistent information about the LTSS available in communities across New York.

Balancing Incentive Program Goals of NWD/SEP

Goals/Targets:

  • Standardize information so that all individuals experience the same eligibility determination and enrollment process.
  • State has a network of NWD/SEPs and an Operating Agency; DOH is the Oversight Agency.
  • NWD/SEPs have access points where individuals can inquire about community LTSS and receive comprehensive information, community LTSS program options counseling, and enrollment assistance.
  • The NWD/SEP system includes an informative community LTSS website and a 1–800 number.
  • State advertises the NWD/SEP system to help establish it as the "go to system" for community LTSS.

Current Status:

  • Inter–agency Work Group meets bi–weekly (DOH, SOFA, OMH, OPWDD, OASAS).
  • The approved BIP application identified the need to expand and enhance NY Connects both functionally and geographically.
  • Work Group is developing the system to expand and enhance the NY Connects structure across populations and the state.
  • Initial overview of the system is in final stages of design.
  • List of potential NWD/SEPs has been provided to CMS.

Challenges/Next Steps:

  • An RFP for the system Technical Detail Specifications is in development.
  • State will need to promote NWD/SEP as the "go to system" or gateway to information about community–based LTSS.

Challenges/Next Steps continued:

  • Agencies becoming part of the NY Connects network will need to transform their business model to conform with operational standards.
  • Agencies will have to learn new systems in order to provide general information and be accessible across "all populations."
  • Agencies will need to have staff trained on the new system, enhanced functions, and the interpretation of screening results.

Balancing Incentive Program Structural Change 2

Core Standardized Assessment (CSA):

  • Identifies the support needs and information on service planning and is used across the state and across a given population.
  • Must meet the Core Data Set (CDS) requirements outlined in BIP guidance.
  • Leverages the Uniform Assessment System (UAS–NY).
  • The assessment is completed by a qualified professional.

Balancing Incentive Program Core Standardized Assessment / Core Data Set (CDS)

Goals/Targets:

  • Develop a Level I screen with a minimal number of questions to indicate eligibility for Medicaid–funded community LTSS.
  • Leverage implementation of NY’s Uniform Assessment System (UAS– NY) to expand across populations (Intellectually Disabled (ID)/Developmentally Disabled (DD), Mental Health/Behavioral Health(MH/BH) and fulfill the required domains – topics of CMS’s CDS for the Level II assessment.
  • Train qualified professionals and NWD/SEP members to initiate and coordinate the collection of Level II assessments utilizing existing web– based courses.

Current Status:

  • The State has submitted to CMS a crosswalk of assessment tools currently in use that includes all required domains and topics within the specified CDS.
  • DOH is currently implementing UAS–NY using the interRAI suite tools for the aged and disabled population.
  • OPWDD is developing a population specific assessment for the I/DD population that utilizes many of the same assessment elements.
  • OMH has selected the interRAI Community Mental Health Assessment for the adult population and CANS–NY for children.

Challenges/Next Steps:

  • Automation is complex, time consuming and requires IT expertise.
  • Timing of implementation across agencies differs.

Balancing Incentive Program Structural Change 3

Conflict Free Case Management (CFCM) optimally involves:

  • Separation of case management from direct services provision. The case manager’s responsibility is to develop a plan of supports and services based on the individual’s assessed needs.
  • Separation of clinical eligibility determination and care planning assessment from direct services provision. Eligibility is determined by an entity or organization that has no fiscal relationship to the individual.

When overlaps do occur, an effective CFCM system mitigates these conflicts through:

  • Independent evaluation. A person who is related (through blood or marriage) to the individual or to any paid caregiver of the individual, or who serves as the individual’s financial or health representative may not perform evaluations or assessments or develop plans of care for the individual.
  • Establishment of firewalls and appropriate safeguards. Monitoring and state oversight assures consumer choice and protects consumer rights.

Balancing Incentive Program Conflict Free Case Management

Goals/Targets:

  • Identify areas of possible conflict and existing mitigation strategies in case management.
  • Establish protocol to remove/mitigate conflict in community LTSS eligibility determination/enrollment, case management processes and service delivery.
  • Develop an independent process to assure that person–centered plans meet the needs of individuals served in community–based settings.

Current Status:

  • The state has submitted to CMS a description of potential conflicts that may exist across programs and agencies as well as strategies currently in place to mitigate risks.

Challenges/Next Steps:

  • CFCM within a managed care environment – a common problem for many states implementing BIP.
  • Decide how to remove or mitigate conflict – may require organizational change, process change, state oversight or administrative firewalls.
  • Clarify the scope of the CFCM requirements internally across agencies and programs.

Balancing Incentive Program 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.

What can BIP funds be used for:

  • BIP funds can be used for: Increased offerings of, or access to, non–institutional LTSS which benefit Medicaid recipients.
  • BIP funds are subject to the same prohibitions as Medicaid funds:
    Cannot be used to match other Federal Funds, or to supplant, etc.

Balancing Incentive Program CMS Interpretation

CMS has developed a three–part test to help States assess whether the use of enhanced FMAP meets legislative requirements. If a State can answer "Yes" to all three of the following questions, the 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)?

Balancing Incentive Program Funding Plan for Rebalancing

  • This master Funding Plan is a dynamic and fluid tool designed to:
    • Change according to identified need,
    • Encourage providers to serve people within the community, and
    • Create opportunity for Stakeholder involvement.
  • $598.7 million has been allocated to address the following identified gaps in areas of community–based LTSS:
    • Insufficient Community Capacity,
    • Insufficient Financial Incentives for Community Placement,
    • Inefficient Infrastructure, and
    • Inadequate Administrative Resources.

Note: Some funding items are pending CMS approval.
          (BIP Funds cannot be used for institution or capital expenditures).

Balancing Incentive Program Funding Plan

Goals/Targets:

  • Expand availability of community–based residential, support and day service options for populations transitioning from institutional settings (i.e., ID/DD individuals impacted by the closure of developmental centers).
  • Create 24/7 direct Crisis Stabilization Teams for the Mental Health population transitioning to supportive housing.
  • Provide additional housing supports and services for those transitioning out of Skilled Nursing Facilities (SNF), Psychiatric Centers or adult homes.
  • Implement Community First Choice Option to streamline services and increase access to Home and Community Based Services.
  • Incentivize providers to consolidate and reduce administrative functions.
  • Develop standardized screen for determining eligibility for community LTSS.
  • Enhance reimbursements for supported employment and day programs (pending CMS approval).
  • Enhance PACE in non–urban areas (pending CMS approval).
  • RFA for Innovations Demonstration project to think differently and create new solutions (pending CMS approval).

Balancing Incentive Program Sustainability Requirement

Goals/Targets:

  • Develop clear estimates of the cost to maintain structural changes implemented through BIP funding sources.

Current Status:

  • All funding sources to implement BIP structural changes have been identified.
  • The utilization of the enhanced funding has been detailed in the BIP funding plan.

Challenges/Next Steps:

  • The development of a comprehensive sustainability plan to maintain the implemented structural changes.

Balancing Incentive Program Data Collection and Reporting

Three Types of Data Are Required:

  1. Service Data – State must report the percent of funds spent on community–based LTSS from claims and other data sources.
  2. Quality Data – State must report its collection and dissemination of quality data and outcome measures.
  3. Outcome Measures – State must evaluate beneficiary and caregiver satisfaction.

Balancing Incentive Program Data Collecting and Reporting

CMS Requirements:

  • States must report service, outcome and quality measure data to CMS.

Current Status:

  • An Interagency Work Group is creating a catalog of quality tools and surveys.
  • A Data Collection Protocol has been identified for semi–annual reporting to CMS.

Challenges:

  • Uniformity of data measures across programs and agencies.

Balancing Incentive Program Housing (State Specific)

Goals/Targets:

  • Housing requirements set forth in the BIP work plan by CMS are specific to New York State.
  • These work plan requirements relate to the Individuals with Intellectual and Developmental Disabilities (I/DD) populations and are also included in the "transformation agreement."
  • The BIP funding plan supports these housing requirements and also provides additional funds for housing supports and services across all populations served by Medicaid.

Current Status:

  • Strategies for building housing options for the I/DD populations transitioning to community settings have been developed and are included in the BIP work plan.
  • BIP funding for assistance across populations is not prescribed; so, there is opportunity for stakeholders to be involved in developing the specifics.

Challenges/Next Steps:

  • Creation and implementation of alternative settings depends on varying regional capacity and composition.

Balancing Incentive Program and the OPWDD Transformation

  • The OPWDD Transformation agreement is a long–term plan with strategies to move to a person–directed system that is primarily community–based.
  • BIP is a CMS challenge to states to provide the most cost–effective community–based services, care and supports in the least restrictive non–institutional setting.
  • Through BIP, CMS is providing the State with an enhanced FMAP to expand, enhance and make structural changes to its community–based service delivery system.
  • Together, OPWDD and DOH are pursuing policies and opportunities for individuals with disabilities to receive services and care in the least restrictive, community–based settings.
  • The BIP funding allows New York to move forward on OPWDD transformation efforts, and where initiatives are included in both the BIP work plan and the OPWDD Transformation Agenda, staff are working cross–agency to assure coordination.

Balancing Incentive Program and MFP Common Goals

  • The Balancing Incentive Program and Money Follows the Person Demonstration:
    • Share a rebalancing goal;
    • Provide enhanced funding which complement the program requirements:
      • MFP funding can be used for the implementation of broader infrastructure developments such as "no wrong door" access to care systems;
    • Are designed to work together and across populations;
    • Are challenged by moving into MLTC environments.

Balancing Incentive Program Next Steps and Challenges

  • Biggest challenge may be Conflict Free Case Management. BIP funding will be used, in part, to assure sufficient plans and provider options in less populated counties and for more difficult–to–serve members to attract additional plans/providers and enhance consumer choice.
  • Agencies becoming part of the NY Connects network will need to change to adhere to new operational standards.
  • Items pending CMS Approval, may require the State to eliminate identified action items and/or create new action items.
  • Time frame to spend funds.

Contact Us:

Resources:

E–mail: BIP@health.ny.gov

URL for the manual: www.balancingincentiveprogram.org

MRT website:
http://www.health.ny.gov/health_care/medicaid/redesign/

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