Demonstration Proposal to Integrate Care for Dual Eligible Individuals: FIDA Update

Mark Kissinger, Director,
Division of Long Term Care

April 18, 2013

Meeting Agenda

  • Welcome/Introductions
  • FIDA Update:
    • Proposal Status
    • FIDA Application
    • Memorandum of Understanding (MOU)
    • Next Steps
  • Comments/Questions

Update - FIDA Demonstration Implementation: Proposal Status

  • FIDA proposal was submitted to CMS on May 25, 2012.
  • Proposal amendment will be submitted CMS this week.
    • Increases the FIDA population by adding dually eligible nursing home residents receiving facility-based LTSS

Update - FIDA Applications

  • Applications were due to CMS via HPMS by February 21st.
  • No additional applications can be submitted.
  • CMS will score the application, along with the 11 CMS-required Model of Care (MOC) elements.
    • Plans will have an opportunity to cure deficiencies during the cure period, if they receive a score below 70.
  • The State will score the 12th MOC element on self direction.
    • Plans that have submitted insufficient or incomplete responses to this element will have two additional opportunities to resubmit this element in HPMS.
    • The first cure period was in April 2013. The second will likely be in May 2013.

Update - FIDA Demonstration Implementation: Draft MOU Development

  • CMS requested that NYSDOH submit a marked up draft of the Ohio Demonstration´s Memorandum of Understanding.
    • This is the starting point for negotiations between NYSDOH and CMS to finalize the specifics of the demonstration.
    • NYSDOH has submitted the MOU in draft form and has made revisions based on CMS comments.
    • The following slides reflect what has been submitted to CMS in draft form. The MOU is subject to change during discussions with CMS.
  • CMS has directed the State to have two separate MOUs (1) FIDA Primary (2) FIDA OPWDD.
  • Plan Selection Process
    • Plans currently operating as MLTC plan are eligible to serve as a FIDA plan.
      • To be approved as a FIDA Plan, MLTC plans will have to meet all FIDA requirements - which include submitting a successful Capitated Financial Alignment Application (i.e., Medicare-Medicaid Plan application) to CMS.
      • Information provided to eligible individuals will clearly specify the choice of FIDA or PACE and PACE enrollees will not be passively enrolled into FIDA plans.
    • NYSDOH is developing a State-specific application process and will announce it soon.
    • NYSDOH anticipates beginning the plan selection process in early summer which will reflect all applicable State law and regulations, as well as the FIDA program requirements.
    • These selections are contingent on the selected entities passing a CMS and State sponsored readiness review. Upon final selection, the State and CMS will ultimately enter into a three-way contract with selected plans.
  • Eligible Populations
    • Age 21 and older at the time of enrollment;
    • In need of over 120 days of community based long-term support services or are nursing facility clinically eligible and receiving facility-based LTSS (this is NEW);
    • Eligible for full Medicare Parts A, B and D and full Medicaid;
    • Reside in a FIDA demonstration County;
    • Do not reside in an OMH facility; and
    • Are not receiving services from the OPWDD system.
  • Proposed Enrollment Process
    • In April 2014, begin accepting voluntary enrollments for individuals in need of community-based long-term care services greater than 120 days.
    • In July 2014, begin process of passive enrollment notification for individuals in need of community-based long-term care services greater than 120 days.
    • In October 2014, begin accepting voluntary enrollment for dual eligible individuals that have exhausted Medicare benefit in nursing homes.
    • In January 2015, begin process of passive enrollment notification for dual eligible individuals that have exhausted Medicare benefit in nursing homes.
    • This will be applicable to eligible individuals in the FIDA demonstration area.
    • Eligible individuals can opt-out of passive enrollment.
    • Enrollment broker will provide enrollment counseling and assistance.
  • Person-Centered Service Planning
    • Assessment and service planning to be completed by an Interdisciplinary Team (IDT), which will be comprised of:
      • Participant and/or his/her designee;
      • Designated care manager;
      • Primary care physician;
      • Behavioral health professional;
      • Participant´s home care aide; and
      • other providers either as requested by the Participant or his/her designee or as recommended by the care manager or primary care physician and approved by the Participant and/or his/her designee.
    • IDT service planning, care coordination and care management will be based on the assessed needs and articulated preferences of the Participant.
    • For OPWDD-FIDA plans, the person´s care coordinator will have experience working with people with developmental disabilities.
    • Consumer direction is included in the covered services and in the service planning process.
  • Network Adequacy and Access
    • Same as was outlined in Appendix E of Demonstration Proposal.
    • FIDA plans will be required to either enter into a contract with or make a payment relationship with all nursing facilities in the FIDA area.
  • Participant Ombudsman (PO)
    • Contingent upon available funding.
    • Will provide advice, information, referral and direct assistance and representation in dealing with the FIDA plans, providers, or NYSDOH.
    • Will be required to regularly report on its work to the State.
    • FIDA plans will be required to notify Participants of the availability of the FIDA PO in enrollment materials, annual notice of grievance and appeal procedures, and all written notices of denial, reduction or termination of a service.
  • Covered Benefits - Same as listed in App. C of Demonstration Proposal
    • NYSDOH is proposing to use the NY Medicaid definition of medical necessity for all services.
    • FIDA plans will have discretion to supplement covered services with non-covered services or items where so doing would address a Participant´s needs, as specified in the Participant´s Person-Centered Service Plan.
  • Model of Care
    • NYSDOH proposed to add 1 element to the 11 NCQA MOC elements:
      • Self Direction
  • Grievances and Appeals
    • NYSDOH proposes 1 consolidated process for Grievances and 1 consolidated process for Appeals:
      • Elements include Medicare and Medicaid processes that are most favorable to the consumer.
      • If approved by CMS, proposed processes will require waiver of some Medicare requirements to implement.
  • Integrated Grievance and Appeal Notices
    • Notification of all applicable Medicare and Medicaid appeal rights through a single notice specific to the service or item type in question, developed jointly by the State and CMS.
    • All notices shall be integrated and shall communicate the steps in the integrated appeals process as well as the availability of the Participant Ombudsman to assist with appeals.
  • Integrated Marketing Materials
    • The State and CMS will work to develop a single consolidated set of marketing rules and requirements and the three-way contract will require FIDA plans to comply with any unified set of rules and requirements that are developed.
  • Quality Metrics
    • MOU contains CMS Core Quality Measures and other measures that the State will utilize. This is a comprehensive list that includes most of the recommendations of this fall´s workgroup.
  • Next Steps
    • Continue discussions with CMS regarding the MOU.
    • Finalize/release State-specific FIDA application.
    • Release guidance to plans on the plan benefit package and non-Part D drugs.
    • Finalize the rate package.
    • Hold next stakeholder meeting in June.

Questions