Summary of FIDA Reforms

FIDA: New Flexibility Offered

December 9, 2015

• Summary also available in Portable Document Format (PDF, 121KB)

At the core, Fully Integrated Duals Advantage (FIDA) remains true to its original key components:

• Fully integrated delivery of Medicaid and Medicare services
• Person-centered care that promotes independence in the community
• Improved quality through care coordination
• High quality cost-effective health care

To enhance the ease and value of FIDA, the NYS Department of Health (DOH) and the Centers for Medicare and Medicaid Services (CMS) have reformed the program, with specific attention to improved flexibility for Participants, Plans, and providers:

• The Participant´s right to choose the make-up of the Interdisciplinary Team (IDT):
  • The IDT can be small, consisting of just a Care Manager and Participant, or broader, with a variety of members (from the original IDT list).
• More flexible IDT:
  • Provider participation in an IDT is adjustable, depending on member availability, items being discussed in a given meeting, or the needs, wishes, and goals of the Participant.
  • Primary Care Providers may review and sign off on a completed Person Centered Service Plan (PCSP) without attending IDT meetings.
  • IDT members may meet at different times. The Care Manager may separately meet with different IDT members in developing the PCSP.
  • Plans have authorization over any medically necessary services included in the PCSP that are outside of the scope of practice of IDT members.
  • IDT training will be encouraged, but not mandatory.
• Simplified procedures:
  • Plans and IDTs have more flexibility in how and when the IDT members communicate with one another.
  • Plans retain responsibility for effective and efficient information sharing among providers (including non-IDT members), including any PCSP revisions.
• Ease of transition and timing of assessments:
  • Plans may use the existing MLTC schedule for completion of a Participant´s Uniform Assessment (UAS) if the Participant is transferring from a sister MLTC/PACE/MAP plan; i.e., each FIDA enrollee transferring from a sister plan need not complete a new assessment until six months from the date of their last MLTC assessment.
    • The FIDA Plan must contact the Participant and review any available medical record and claims history from the pre-enrollment period to determine changes in health status, health event, or needs that would trigger an updated UAS.
    • If an updated UAS is required, it will be conducted within six months of the last UAS, and development of PCSP implemented within 90 days following the enrollment effective date.
  • All other Participants have a PCSP deadline of 90 days from the enrollment effective date.
• Assurance Participant satisfaction:
  • DOH/CMS and the Contract Management Team (CMT) will evaluate the FIDA Plan´s IDT delivery and operations.
  • Specifically, the CMT will assess a Plan´s IDT performance against the following existing measures:
    • In the last six months, did anyone from the Participant´s health plan, doctor´s office, or clinic help coordinate care among these doctors or other health providers?
    • How satisfied is the Participant with the help in coordinating care in the last year?
    • What is the percentage of Participants discharged from a hospital who were readmitted within 30 days, either for the same condition as their recent hospital stay or for a different reason?
    • What is the percentage of patients 65 years or older discharged from any inpatient facility and seen within 60 days following discharge by the physician providing on-going care, who had a reconciliation of the discharge medications with the current medication list in the medical record documented?
    • What is the total percentage of all Participants who saw their primary care doctor during the year?
    • What is the percentage of Participants in the FIDA Demonstration who reside in a nursing facility (NF), wish to return to the community, and were referred to preadmission screening teams or the Money Follows the Person Program?
    • What is the number of nursing home-certifiable Participants who lived outside the NF during the current measurement year as a proportion to those during the previous year?
    • Follow-up required after Hospitalization for Mental Illness.
  • FIDA Plans must meet Medicare-Medicaid Plan Model of Care (MOC) elements and consistently update MOCs to reflect changes to the IDT Policy.
• More Plan Flexibility:
  • Plans are allowed to market multiple lines of business under the more flexible Medicare Marketing Guidelines.
  • Plans are allowed to provide a written or verbal comparison (either DOH/CMS prepared or plan-prepared) among their MLTC (Partial, PACE, MAP) and FIDA products and among their MLTC programs, and the FIDA program.
  • Plans are allowed to make outbound FIDA marketing calls to individuals enrolled in any other Medicaid or Medicare product line with the Plan/company.
  • Plans are allowed to conduct in-person marketing appointments if these appointments are solicited by the individual.
  • Plans are allowed to conduct promotional activities and make nominal gifts at the Medicare Marketing Guidelines levels ($15).
  • Plans are allowed to send, with a prior approval from DOH, FIDA educational materials (e.g., one-page letters, newsletters, etc.) to participants who have opted out.
  • Plans will not have to include both the plan phone number and enrollment broker number in their marketing materials.
  • Plans are allowed to submit enrollment requests to Maximus (consistent with what they do in MLTC). Maximus will process the enrollment and send letters to the individuals confirming their enrollment in FIDA. The letters will contain the ICAN contact information.
  • Plans are allowed to stay on the phone with prospective Participants when they call Maximus.
• Medicare Rate update:
  • CMS has committed to reviewing its payment of health plans participating in the demonstration in addition to increasing rates for 2016 to offset the CMS-HCC risk adjustment model´s under prediction of costs for full benefit dual eligible beneficiaries.
  • CMS is conducting additional analysis of the Part D bids.
  • CMS is open to reconsidering the assumptions used in determining the adjustment for CY 2016 based on revised projections of enrollment and recent experience in the demonstration.
• 2016 Enrollment:
  • Future passive enrollment is suspended until further notice.
  • Enrollment in Region 2 (Suffolk and Westchester Counties) will not start until after mid-2016.
• Reporting:
  • Completion of the bi-weekly and monthly dashboards is no longer required.
  • DOH/CMS will streamline several reporting measures (e.g., NY1.1, NY1.2, and NY2.1) based on the new IDT policy (to be released). Changes to these measures would be applicable beginning with the 4th quarter of 2015 (October - December) reporting period.
• Quality Withhold (QW):
  • Effective upon execution of the Three-way Contract Amendments.
  • The 2015 and 2016 quality withhold payments will be tied to participation through December 31, 2016. This will essentially add a new criterion to the QW calculation that excludes an organization from receiving QW amounts if the organization does not participate at least through 2016. (QW amounts are 1% of rate in 2015 and 2% in 2016).
  • For any Plans that do not continue through December 31, 2016, quality withhold amounts from 2015 and 2016 will be pooled and added to amounts earned by FIDA Plans participating on January 1, 2017 (based on 2016 performance).
• ADA Attestation Form:
  • No provider should be terminated from a FIDA Plan network for not answering in the affirmative to elements on the form.
  • The form is to help FIDA participants identify which providers offer specified accessibility features.
  • Completion or non-completion of the form, or responding in the affirmative to elements included does not alter existing obligations to comply with the ADA.
  • FIDA Plans must maintain a complete and accurate provider directory, including information collected by the form. FIDA Plans have discretion on how to address provider refusals to complete the form.