Letter and Frequently Asked Questions for Home Health Providers

• FAQs are also available in portable document format (PDF, 167KB, 4pg.)

FULLY INTEGRATED DUALS ADVANTAGE (FIDA)

Frequently Asked Questions

What is FIDA?

FIDA stands for Fully Integrated Duals Advantage. It´s a program jointly administered by the federal Centers for Medicare & Medicaid Services (CMS) and the New York State Department of Health (NYSDOH), and is designed to integrate care for New Yorkers who have both Medicare and Medicaid. The main goal of FIDA is to increase health care access and organize care around the unique needs and preferences of the individual and to improve their health outcomes and satisfaction. FIDA builds off the existing Managed Long-Term Care (MLTC) program.

What services will FIDA cover?

Eligible individuals will receive full Medicare and Medicaid coverage, long-term care, Part D and Medicaid drugs, and additional benefits from a single, integrated managed care plan. In other words, FIDA will cover all the benefits that your patients may receive today through their managed long-term care (MLTC) plan, Original Medicare or their Medicare Advantage plan, and their Part D plan. A list of the minimum FIDA covered items and services are available at the Information and Guidance for Plans page under the section labeled Summary of Benefits - English & Spanish (2015).

Under FIDA, individuals will have access to all home health services covered by Medicare and Medicaid. Medicare home health services include intermittent skilled nursing care, physical therapy, continuing occupational therapy, speech-language pathology, home health aide services, and medical social services. Medicaid home health services include nursing services, home health aide services, medical supplies, equipment and appliances, physical therapy, occupational therapy, or speech pathology and audiology services.

What changes should home health providers be aware of under the FIDA program?

• Home health providers should bill the FIDA Plan directly for all services, rather than bill Medicare or a New York Medicaid MLTC Plan separately.
• Unless a contract between a provider and FIDA Plan specifies otherwise, there is no need for a provider to differentiate whether the services are covered through Medicare or Medicaid.
• Except for certain circumstances, a home health agency must be contracted with a member´s FIDA Plan to receive payment.
• Home health agencies and FIDA Plans may execute contracts with payment terms that are different from Medicare fee-for-service. This presents an opportunity to establish payment models that support best practices in clinical care.

How will home health services be authorized under the FIDA program?

As in MLTC and Medicare Advantage, FIDA Plans will pay for any covered items or services that are medically necessary and authorized when required. This applies to home health care services, too. However, unlike in MLTC or Medicare Advantage, home health services may be authorized either by the FIDA Plan or by the individual´s care team ("Interdisciplinary Team," or "IDT").

Service authorizations may be made by the FIDA Plan through the traditional utilization management (UM) process before an individual´s care plan ("Person-Centered Service Plan," or "PCSP") is developed by the care team. Once the care plan is in place, the care team´s decisions included in the care plan act as service authorizations. These service authorizations may not be modified by the FIDA plan except in cases where the individual (or providers, designees, and/or representatives acting on behalf of the individual) appeals the care team´s service authorizations.

Who is eligible for the FIDA program?

Since FIDA builds upon the existing MLTC program, the vast majority of people enrolled in an MLTC plan are also eligible for a FIDA Plan. In general, individuals must:

• Reside in any of the New York City boroughs or Nassau county,
• Be 21 years or older, and
• Be entitled to Medicare Part A, enrolled in Medicare Part B, and eligible to enroll in Part D, and receiving full Medicaid benefits; and
• Require community-based long-term services and supports (LTSS) for more than 120 days per year or be eligible for but not already receiving facility-based or community-based LTSS ("New to Service").

When can individuals enroll in FIDA Plans?

Generally, eligible individuals can enroll in FIDA Plans at any time. Those that are subject to passive enrollment will receive notices indicating the name of their FIDA Plan along with important information about the program and the phone number to call if they have questions or want to opt out.

Is FIDA mandatory for dually eligible participants in New York State?

No. FIDA is not mandatory for anyone in New York State. Individuals can opt out of FIDA at any time, before or after passive enrollment, to keep their Medicare and Medicaid benefits the same as they are today.

Can I continue to see my clients who join a FIDA Plan even if I am not participating?

Generally, eligible individuals can enroll in FIDA Plans at any time. Those that are subject to passive enrollment will receive notices indicating the name of their FIDA Plan along with important information about the program and the phone number to call if they have questions or want to opt out.

Is FIDA mandatory for dually eligible participants in New York State?

No. FIDA is not mandatory for anyone in New York State. Individuals can opt out of FIDA at any time, before or after passive enrollment, to keep their Medicare and Medicaid benefits the same as they are today.

Can I continue to see my clients who join a FIDA Plan even if I am not participating?

Yes, for a limited time. FIDA includes important continuity of care provisions:

• All individuals new to a FIDA Plan will have a transition period during which they can continue their current course of treatment with any home health providers they have seen in the past 6 months, regardless of whether those providers are in the FIDA Plan´s network or not. The transition period will last for at least ninety (90) days.
• During this period, FIDA Plans are required to pay out-of-network home health providers at least the lessor of the providers´ charges or the Medicare fee-for-service rate.
• After this period, individuals will need to see home health providers in their FIDA Plan´s network and the FIDA Plan will no longer be required to pay for the care received out-of-network, unless the FIDA Plan or the individual´s care team has authorized it.

For more information on the continuity of care provisions, please refer to Section 2.6.6 on page 68 of the FIDA Three-Way Contract at: http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/NewYorkContract.pdf.

Can home health providers join the FIDA Plans´ networks?

Home health providers are encouraged to join FIDA Plans´ networks to provide continuous care to eligible individuals and to be part of this important initiative to coordinate care for Medicare and Medicaid beneficiaries. The list of FIDA Plans is included with this letter below. FIDA Plans build off of the existing MLTC Plans operating under the same parent company. As such, the home health and other LTSS providers in the MLTC Plan´s network are likely to also be in the FIDA Plan´s network.

Can a FIDA participant appeal the FIDA Plan´s or the care team´s authorization for home health services?

FIDA participants, or anyone acting on their behalf and with their written consent, may appeal any service authorization or any adverse UM action. All appeals should first be directed to the FIDA Plan. Individuals also retain their Medicare QIO home health appeal rights.

Will home health providers still be required to complete OASIS documents, obtain face-to-face documentation, and follow Medicare coverage requirements?

Nothing in the FIDA program changes the Medicare certification requirements for home health agencies (HHA). Any HHA seeking Medicare certification is required to meet the Medicare Conditions of Participation (CoP) prior to certification. This includes compliance with the OASIS (the Outcome and Assessment Information Set) data set collection and transmission requirements.

As in Medicare Advantage, a FIDA Plan´s authorization for home health services may substitute for the Original Medicare face-to-face certification requirement for the authorization of home health care services. In certain circumstances, FIDA Plans are not required to follow Original Medicare documentation requirements for the provision of Medicare-covered services, but may substitute methods they deem appropriate for ensuring that the services provided are medically necessary, so long as they are not more restrictive than the coverage standards that apply in Original Medicare.

Under FIDA, home health providers will bill all home health services directly to the FIDA Plan. If a determination of medical necessity is made for home health services, Medicare homebound requirements for coverage are not relevant.

Will providers still be required to deliver advance beneficiary notices when home health services are terminated?

Yes. Home health providers must give individuals a completed copy of the Notice of Medicare Non-Coverage (NOMNC) prior to termination of Medicare-covered, home health (including psychiatric home health) services. Medicare Advantage NOMNC rules continue to apply in FIDA. However, in accordance with the Medicare rules, the NOMNC should only be issued when services are terminated. This means the NOMNC should not be issued if the FIDA participant continues to receive home health services.

How can my clients get help understanding their coverage options?

For questions about FIDA, individuals can call New York Medicaid Choice at 1-855-600-3432 (free interpreter: 1-855-600-3432). They can also call the new ombudsman program - the Independent Consumer Advocacy Network (ICAN) at 1-844-614-8800.

For questions about Medicare benefits and Medicare Advantage plans, individuals can call Medicare at 1-800-MEDICARE (1-800-633-4227). They can also call the Health Insurance Information, Counseling, and Assistance Program (HIICAP) at 1-800-701-0501.

How can I find out more about FIDA?

If you have questions regarding FIDA, please email the New York State Department of Health at fida@health.ny.gov or visit the FIDA website at: https://www.health.ny.gov/health_care/medicaid/redesign/fida/

FIDA Plans:

Organization Name	FIDA Plan Name	Kings	Queens	Bronx	New York	Richmond	Nassau
Aetna Better Health of New York	Aetna Better Health FIDA	X	X		X		X
AgeWell New York, LLC	AgeWell New York FIDA	X	X	X	X		X
AlphaCare of New York, Inc.	AlphaCare Signature FIDA	X	X	X	X
Amerigroup New York, LLC	HealthPlus Amerigroup FIDA	X	X	X	X	X
Archcare Community Life	ArchCare Community Advantage FIDA	X	X	X	X	X
Centerlight Healthcare, Inc.	CenterLight Healthcare FIDA	X	X	X	X	X	X
Centers Plan for Healthy Living, LLC	FIDA Care Complete	X	X	X	X	X
ElderPlan, Inc.	ElderPlan FIDA Total Care	X	X	X	X	X	X
Elderserve Health, Inc.	RiverSpring FIDA	X	X	X	X	X	X
Fidelis Care of NY	Fidelis Care FIDA	X	X	X	X	X	X
GuildNet, Inc.	GuildNet Gold Plus FIDA	X	X	X	X	X	X
Managed Health (HealthFirst)	Healthfirst AbsoluteCare FIDA	X	X	X	X	X	X
Health Insurance Plan of Greater New York (HIP)	EmblemHealth Dual Assurance FIDA	X	X	X	X	X	X
Independence Care Systems, Inc.	ICS Community Care Plus FIDA MMP	X	X	X	X
Integra MLTC Inc.	Integra FIDA	X	X	X	X	X	X
MetroPlus Health Plan	MetroPlus FIDA	X	X	X	X
NorthShore-LIJ Health Plan, Inc.	North Shore-LIJ FIDA LiveWell	X	X		X	X	X
Senior Whole Health of New York, Inc.	SWH Whole Health FIDA	X	X	X	X
VillageCareMAX	VillageCareMAX Full Advantage FIDA	X	X	X	X
VNS Choice	VNSNY Choice FIDA Complete	X	X	X	X	X	X
Wellcare of NY, Inc.	WellCare Advocate Complete FIDA	X	X	X	X	X	X