Fully Integrated Duals Advantage (FIDA) Overview and Update Stakeholder Webinar

Mark Kissinger, Director, Division of Long Term Care
Joseph Shunk, Acting FIDA Project Director

Office of Health Insurance Programs
New York State Department of Health

September 9, 2015

What is FIDA?

  • FIDA is a partnership between the Centers for Medicare and Medicaid Services (CMS) and DOH.
  • Through FIDA, certain dual eligible individuals (Medicaid and Medicare) will be enrolled into fully-integrated managed care plans.
  • FIDA is operational in New York City and Nassau County and the demonstration period runs from January 2015 to December 2017. Westchester and Suffolk Counties will begin in 2016. DOH has submitted a request for extension and if approved by CMS the program would run through December 2019.
  • The FIDA program is currently being offered by 18 Health Plans in New York City and Nassau County.

Vision for FIDA

  • Improve the Participant's experience in accessing care;
  • Deliver person-centered care that promotes coordination;
  • Promote independence in the community;
  • Improve quality through improvements in care and coordination;
  • Develop a more easily navigable and simplified system of services for individuals and their families;
  • Ensure access to needed services and incorporate Participant protections;
  • Meet robust network adequacy standards for both Medicaid and Medicare; and
  • Evaluate data on access, outcomes and experience to ensure Participants receive higher quality care.

Key Highlights of FIDA

  • Builds off of Managed Long Term Care (MLTC);
  • Provides a comprehensive benefit package;
  • Provides a Care Manager and an Interdisciplinary Team (IDT);
  • Integrates the grievance and appeal process, excluding Part D;
  • Utilizes an independent enrollment broker (NY Medicaid Choice) to assist with enrollment and options counseling; and
  • Access to the Participant Ombudsman: Independent Consumer Advocacy Network (ICAN).

Who is Eligible for FIDA?

  • Eligible individuals:
    • Are age 21 or older at time of enrollment;
    • Are entitled to benefits under Medicare Part A, enrolled under Part B, eligible to enroll in Part D, and receiving full Medicaid benefits; and
    • Reside in New York City, Long Island, or Westchester County.
  • And must meet one of the following:
    • Require more than 120 days of community-based long term care; or
    • Are Nursing Facility Clinically Eligible and receiving facility-based long term services and supports (LTSS); or
    • Are eligible for the Nursing Home Transition and Diversion Waiver program.

FIDA Enrollment

  • There are two types of enrollment:
    • Opt-in Enrollment, which is initiated by an individual.
    • Passive Enrollment, which is enrollment by the State which the individual can decline by opting out.
      • Individuals who are eligible for FIDA and enrolled in a MLTC Plan will "convert in place" to the FIDA Plan offered by the parent organization of their MLTC Plan.
  • Participants may opt out of passive enrollment or disenroll at any time.
  • Those who opt out or disenroll will continue to receive Medicaid services through the MLTC program and have a choice of Original Medicare or Medicare Advantage and a prescription drug plan.
  • Participants who have opted out may rejoin the program at any time.

FIDA Enrollment Update

  • Passive Enrollment was conducted in April, May, July, August, and September in the five boroughs of New York City and Nassau County.
  • As of September 1, 2015, there were approximately 7,300 individuals enrolled in FIDA.
  • The next wave of Passive Enrollment will be effective on October 1, 2015.

Why Should Individuals Join FIDA?

  • FIDA provides full Medicare and Medicaid coverage, long term care services, Part D and Medicaid drugs, and additional benefits from a single, integrated managed care plan. FIDA covers all the benefits that the individual may receive through their MLTC Plan, Original Medicare or their Medicare Advantage Plan, and their Medicare Part D Plan.
  • FIDA covers additional services most of which are not currently available through MLTC Plans, for example:
    • Home and community support services
    • Mobile mental health treatment
    • Peer mentoring
    • Positive behavioral interventions and support
  • FIDA provides a Care Manager who can schedule doctor's appointments, arrange transportation and help Participants get their medicine.
  • FIDA encourages Participants, caregivers, and providers to make care decisions together via an IDT.
  • Pay NO deductibles, premiums, or copayments/coinsurance;
  • NO referrals to see specialists;
  • Use one phone number to call the Plan for all questions regarding their benefits; and
  • Use one ID card to receive all of their benefits.

Why Should Current Providers Participate in FIDA?

  • FIDA will allow providers to collaborate with other providers as part of a care team for all of an individual's care needs to develop a single, customized care plan to address all of the Participant's specific needs.
  • FIDA will save providers time, as the FIDA Care Manager will document the Participant's care plan, and any changes to it; help the Participant schedule appointments and arrange for transportation to them; and keep providers informed about any services or care the Participant receives.
  • FIDA may help decrease avoidable hospitalizations by offering providers more opportunities to speak with the Participant and the other members of the care team to make sure the Participant understands and follows the goals of their care plans. The FIDA Care Manager will be responsible for ensuring an individual's access to important follow-up care.
  • FIDA will streamline the administrative claims processing, since there is one billing process and one payer (the FIDA Plan) for both Medicare and Medicaid services.

Receiving Care in FIDA

FIDA Care Coordination and the IDT

  • Each Participant has his/her own IDT that engages with the Participant in care planning and care coordination.
  • For each Participant, FIDA Plans will support an IDT to ensure the integration of the Participant's medical, behavioral health, community-based or facility-based LTSS, and social needs.
  • The IDT is person-centered, built on the Participant's specific preferences and needs, and delivers services with transparency, individualization, accessibility, respect, linguistic and cultural competence, and dignity.
  • The FIDA Plan Care Manager is the lead, facilitates all IDT activities, and conducts ongoing care management activities.
  • The Care Manager is responsible for coordinating, arranging, and ensuring receipt of these services.

A Participant's IDT must be made up of:

  • The Participant or, in the case of incapacity, an authorized representative;
  • The Participant's designee(s), if desired by the Participant;
  • A Primary Care Provider (PCP) or a designee with clinical experience from the PCP's practice who has knowledge of the Participant's needs;
  • A Behavioral Health Professional, if there is one, or a designee with clinical experience from the professional's Behavioral Health practice who has knowledge of the Participant's needs;
  • The FIDA Plan Care Manager;
  • The Participant's Home Care Aide(s), or a designee with clinical experience from the home care agency who has knowledge of the Participant's needs, if desired by the Participant;
  • The Participant's Nursing Facility Representative, who is a clinical professional, if receiving Nursing Facility care; and
  • Other Providers as requested by the Participant or designee; or as recommended by the IDT.
  • The RN who completed the Participant's Assessment, if approved by the Participant or designee.

Establishing the IDT

  • Each Participant will actively participate in the IDT which will address their medical, Behavioral Health, LTSS, and social needs.
  • FIDA Plans should identify IDT members and start scheduling the IDT as soon as possible.
    • Plans are currently required to convene the IDT within 30 days of Participants having a comprehensive assessment by an RN.
  • IDT members may be added and removed as needs arise and care has ended.
  • The IDT must convene routinely, and no more than six months from the previous IDT meeting.
  • These meetings may occur more frequently after trigger events.

IDT Authorization

  • The IDT develops the care plan and as a whole is responsible for making coverage determinations and authorizes services.
  • After the care plan is developed by the IDT, care decisions contain therein act as service authorizations for six months or the duration of the care plan.
  • Service authorizations made by the IDT may not be modified by the FIDA Plan; unless modified pursuant to the decision of a Participant appeal.
  • In between IDT meetings, the FIDA Plan (i.e., utilization management) may authorize services.
  • The Participant may appeal any IDT decision, regardless of whether the Participant agreed at the time of the IDT meeting.
  • IDT approval is not required for drugs. However, the IDT may authorize drugs as part of the care plan development process and, at a minimum, is required to discuss and incorporate a list of medications in use by the Participant within the care plan.

IDT Policy Updates

  • DOH and CMS are in the process of updating the IDT Policy to provide flexibility to both Plans and providers. Once finalized, the new policy will be available on https://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm
  • Some of the proposed changes relate to:
    • Greater flexibility for IDT participation
    • Timeframes for meetings and communications
    • Acceptance of electronic signatures and verbal approvals of care plans

Best Practices

  • Some Plans are conducting the IDT meetings in the PCP's office
  • Some Plans have held IDT meetings in the Participant's home
  • Some Plans are reimbursing PCPs for the IDT meeting
  • As soon as some plans are informed of new Participants, they are conducting outreach to the Participant's providers to:
    • alert them of this enrollment, and
    • educate them on their FIDA product.

Positive Feedback

  • Development of positive relationships between Participants and their IDT
  • More collaboration and coordination among providers as a result of the IDT
  • The integrated model allows the IDT members to have a more complete understanding of the Participant's condition
  • Increase in Participant compliance with care plans
  • Increase of family engagement in the care planning process
  • Provides one-stop access for providers for authorization of services and payment
  • NY Medicaid Choice conducted a survey in June of individuals who were passively enrolled, some of the findings include:
    • 87% have been able to keep the doctor most important to them since joining a FIDA Plan
    • 90% were able to keep their home attendant
  • NY Medicaid Choice also surveyed individuals who opted-into the FIDA program, some of the findings include:
    • 93% were able to keep their home attendant

Challenges

  • Lower than expected enrollment numbers
  • IDT logistics
  • Provider participation in the IDT
  • Training requirements

Continuity of Care

  • FIDA Plans must allow Participants to maintain current providers - even if not in the FIDA Plan's network - and service levels, including prescription drugs, for at least 90 days or until a Person Center Service Plan is finalized and implemented, whichever is later.
  • Exceptions to 90-day Continuity of Care:
    • Existing behavioral health service providers must be maintained for up to 24 months;
    • For nursing facility services, FIDA Plans must allow Participants to maintain current providers for the duration of the Demonstration; or
    • If the IDT or the FIDA Plan approves the Participant to see an out of network provider.

The Role of ICAN

  • A FIDA Participant has access to ICAN, which was launched on December 1, 2014.
  • ICAN is an independent, conflict-free entity that provides individuals free assistance in accessing care, filing grievances, appealing adverse decisions, and understanding and exercising rights and responsibilities.
  • Currently, ICAN serves:
    • All four MLTC products (FIDA, Partial, MAP, and PACE)
    • Mainstream Medicaid Managed Care (MMC) enrollees who receive long term care.

Current Status of ICAN

  • The Ombudsman program contract was awarded to Community Service Society of New York, a network of not-for-profit organizations.
  • The network has numerous physical locations throughout NYS, at which Participants can obtain in-person assistance.
  • The call center receives calls from the entire state.
  • ICAN can be reached by calling 1-844-614-8800 or online at www.icannys.org.

FIDA Outreach and Education

  • On September 17 and September 30, 2015, DOH and CMS will hold a FIDA training event for providers, plans, and advocacy organizations in New York City. Continuing education credits will be available to those who attend in person. Unfortunately, there will not be a call-in opportunity at these events. Please see the registration links contained on the Resource slide.
  • Outreach materials for plans, advocacy organizations, and providers are available on MRT 101, which includes a fact sheet, sample newsletters, and power points, see the following link: https://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm.
  • In addition, DOH developed a Participant-friendly website for FIDA, see the following link: www.health.ny.gov/health_care/medicaid/redesign/fida/.

Resources:

QUESTIONS?