Fully-Integrated Duals Advantage (FIDA) Stakeholder Workgroup Plan Qualifications / Quality Metrics

Wednesday, September 12, 2012
2:00 p.m. - 3:00 p.m.

Call summary

On Wednesday September 12, 2012, NYSDOH held its first of three FIDA Plan Qualifications/ Quality Metrics Workgroup meeting for stakeholders. Following is a summary of the meeting discussion.

Attendees

NYSDOH requested that all meeting attendees email Laurie A. Arcuri (laa03@health.state.ny.gov) from NYSDOH to indicate participation on the call.

Overview of FIDA and Workgroup Charge

NYSDOH provided an overview for the workgroup members to the FIDA proposal and the important involvement of stakeholders in shaping the details of the FIDA program as negotiations occur between NYS and CMS. To date, NYSDOH has not received feedback from CMS on the FIDA proposal and have not begun negotiations with CMS; however, NYS is not slated to begin the demonstration until 2014 which leaves ample time for negotiation to occur. At the end of this call summary is a copy of the FIDA overview document that was distributed to workgroup members prior to the call.

NYSDOH has established four stakeholder workgroups as part of the FIDA proposal, each with its own separate charge. The four workgroups are:

  • Finance/Rate Setting. Charge: to provide feedback related to Financing and Payment (including but not limited to): capitalization; solvency; reserves and rates
  • Outreach/Enrollment/Consumer Engagement. Charge: to provide feedback related to beneficiary protections, participation and service benefits (including but not limited to): Plan Choice; Continuity of Care; Enrollment Assistance and Options Counseling; Person- Centered Planning; ADA and Civil Rights Protection; Enrollee Communications; Marketing; Education and Enrollment Process
  • Navigation/Appeals/Grievances. Charge: to provide feedback related to integrated appeals and grievances (including but not limited to): Plan grievances and internal appeals; External Appeals; Enrollment and Disenrollment Processes; Member access and communication supports; Customer service standards; and Member Ombudsman
  • Plan Qualifications/Quality Metrics. Charge: to provide feedback related to plan selection and quality metrics (including but not limited to): Plan Selection Process; Network Adequacy; requirements for Integrated Services, Assessment, Care Planning and Management; Credentialing; Model of Care; and Core Demonstration Measures with focus on NCQA/HEDIS/AHQR/CAHPS/NQF.

Review and Discussion of Known CMS Standards for Plan Selection and Quality

Since NYSDOH has not received feedback from CMS yet on the FIDA proposal, NYSDOH provided an analysis of the MOU that was created between Massachusetts and CMS so the workgroup members could see some issues that were raised and provide a structure to target comments. NYSDOH provided some context for the MA MOU, including the following:

  • Age group in MA project is 21-64 (versus 21 and older in NYS´s proposal)
  • Strategy for plan selection in the MA document has been approved by CMS
  • MA is providing a full range of services-behavioral, primary, LTC support, and pharmacy
  • MA has split care managers but still have patient centered process, interdisciplinary care team
  • Model of care list is particularly relevant for group to review and provide feedback
  • Pharmacy component is also significant to review.
  • Data system specification/interoperability section is also relevant to consider, given that expectations are higher because of the data exchange requirements of CMS in the demonstration

In addition to the MOU, a three-way contract will be developed between MA, the CMS, and Health Plans which could provide another level of detail that the workgroup may want to provide input.

Discussion

Context. A workgroup participant requested some context for considering the FIDA plan elements for NYS in addition to the model provided in the MA MOU. In particular, the group thought it would be helpful to understand NYS´s current approach to the elements ("level-set"). NYSDOH agreed to provide some direction regarding where to access resources located on their website to the group so members that need more information can access it. Workgroup members were also encouraged to do their own research.

Plan selection. The workgroup had a discussion regarding the benefits and drawbacks related to issuing an RFA and selecting plans versus having an open process where plans that meet a set of standards automatically qualify to participate. NYSDOH said that an RFA is more competitive traditionally, but not necessarily. If an RFA is done, the State can have a high degree of specificity about the requirements and needs of population and response of the plan to meet those requirements. Participants saw benefit to the RFA process. A participant asked if the RFA could substitute for the process to become a full-fledged Medicare plan (NYSDOH indicated they could explore the option with CMS). Another participant asked if there would be a way to streamline the application process for plans that already have existing products. In addition, brief discussion was held regarding whether there should be a percentage set for board certification of network physicians (one participant noted that would be challenging because a number of physicians are not board certified) and the number of plans that should take part.

Quality Metrics. NYSDOH stated that the focus will be on quality metrics that are already in place and required for HEDIS reporting. One participant asked if there were any special measures that NCQA developed or is in the process of developing that would be relevant, and then volunteered to research (Joe Baker). Another participant will circulate any NQF measures that may be in development for consideration (Rose Duhan). Information will be sent to NYSDOH to recirculate to the workgroup.

Next Steps

NYSDOH will provide links to relevant current NYSDOH documents to workgroup participants prior to the next meeting, as well as links provided by participants for NCQA and NQF measures. The agenda and any pre-work for the workgroup participants will also be provided prior to the next meeting. Participants requested that the discussion topics be broken down into chunks for easier consideration.

Future session dates and times

Workgroup call #2: Monday, September 24 from 9-11am

Workgroup call #3: Monday, October 22 from 9-11am

Overview
NYSDOH Demonstration Proposal to Integrate Care for Dual Eligible Individuals
Fully-Integrated Duals Advantage (FIDA)

Managed Care Model - Fully-Integrated Dual Advantage (FIDA)

New comprehensive managed care option that is specifically tailored to meet the complex needs of New York´s full dual eligibles. Through Fully-Integrated Duals Advantage (FIDA) program, full dual eligibles who require 120 or more days of Long-Term Supports and Services (LTSS) would be provided the entire range of Medicare and Medicaid services as well as an extensive list of LTSS many of which were previously only available in New York State´s Home and Community-Based Services Waiver programs.

Through the FIDA program, full dual eligibles would be provided with features such as, but not limited to:

  • Seamless access to all physical health, behavioral health, and LTSS;
  • A choice of plan and a choice of providers, with choices being facilitated by an independent, conflict-free Enrollment Broker;
  • Care planning and care coordination by individualized interdisciplinary teams that are centered around each dual eligible;
  • Consumer direction for personal care services;
  • An independent, conflict-free, Participant Ombudsman to aid in any questions or problems the Participant has;
  • Continuity of care provisions to ensure seamless transition into one´s FIDA plan;
  • Articulated network adequacy and access standards; and
  • New Health Education and Wellness benefit.

Background

Qualifying Plans and Governing Rules

While NYSDOH is building the FIDA program requirements from the program requirements for the MAP program, it will, however, contract with MLTC plans in the demonstration service area that are in operation in 2013, that obtain CMS approval to be a Medicare Advantage Plan for 2014 and that are able to meet the requirements of the FIDA program. The MLTCPs are approved to operate based on the Department´s review of their compliance with the MLTC programmatic requirements including a strong care management component, having an adequate contracted network to provide benefit package services, having adequate capitalization and solvency as well as meeting the Public Health Law´s requirement for character and competence of the governing body and controlling persons.

For the FIDA OPWDD program, one to three qualifying plans with a history of high- quality care coordination for people with developmental disabilities will be selected to participate. Eligibility to apply to be an OPWDD FIDA plan is further dependent upon the entity being approved to operate as an MLTCP under the authority of NYSDOH during CY 2013. NYSDOH and OPWDD are pursuing state regulatory and legislative changes to support the establishment of specialized MLTCPs in 2013 for this demonstration.

Participating plans will be required to comply with all Medicare Advantage and Medicaid MLTCP requirements except to the extent that NYSDOH has obtained waiver of applicable provisions. FIDA plans will also be required to comply with all applicable New York State laws and regulations, and all additional requirements contained in the three-way contract being developed by CMS and NYSDOH/OPWDD.

Additionally, NYSDOH will pursue a waiver from CMS to permit any PACE plan that is able to meet the FIDA requirements to participate in the FIDA program.

Description of the Target Population

As of December 2010, there were 755,067 dually eligible Medicare/Medicaid recipients in New York State. Many of New York´s dual eligibles are vulnerable, disabled, frail adults with chronic medical conditions who are significantly functionally impaired and/or have complex mental health and LTSS needs.

The target population for this demonstration is:

  • FIDA - 123,800 full dual eligibles in the eight counties of Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, and Westchester who: 1) Are age 21 or older; 2) Require community-based long term care services for more than 120 days; 3) Are not receiving services through the OPWDD system; and 4) Are not receiving services in an OMH facility.
  • FIDA OPWDD - up to 10,000 full dual eligibles statewide who: 1) Are age 21 and older and 2) Are receiving services through the OPWDD system; and 3) Are not receiving services in an OMH facility.
Dual eligibles in the 8 county service area Overall Individuals receiving LTSS in institutional settings Individuals receiving LTSS in HCBS settings
Overall total 460,109 54,164 123,880
Individuals age 65+ 356,256 49,420 110,102
Individuals under age 65 103,853 4,744 13,778
Individuals with serious mental illness 75,956 20,796 21,112

Geographic Service Area

The FIDA Program will operate in the eight contiguous New York counties of Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, and Westchester. 123,880 full dual eligibles who met the enrollment criteria reside in this service area. This service area was selected because it contains extensive provider and plan capacity.

The FIDA OPWDD Program will be available statewide but selected plan(s) will operate in discrete regions of the state based on the network scope and capacity. Up to 10,000 full dual eligibles who receive services through the OPWDD system will participate in this program.