NHTD and TBI Waiver Transition Workgroup Meeting

January 26, 2017, 10:30 am – 12:30 pm

One Commerce Plaza, Room 1613

• Meeting Minutes is also available in Portable Document Format (PDF)

Welcome and Introduction, David Hoffman, Bureau Director, Bureau of Community Integration and Alzheimer´s Disease

• Introduction of workgroup members
• FAQ document distributed ("Questions generated from responses to the NHTD/TBI Waiver Transition Plan November 16, 2016")
• Review of meeting agenda:
  1. Transition Update, Jason A. Helgerson, Medicaid Director, Office of Health Insurance Programs
  2. Training Curricula – Audience and Content
  3. Updates
  4. Review of Frequently Asked Questions
  5. Open Discussion – Questions and Comments
  6. Next Steps
• There are currently two UAS initiatives:
  1. IPRO audit in New York for which the final report is not yet available; and
  2. University of Michigan/InterRAI product. The results of the national panel review are not yet finalized.

Training Curricula: Audience and Content

• Training for different audiences to include participants/families, the waiver provider community, and those who provide care/community/staff.
• NYSDOH is not intending to direct these groups. We anticipate development of a sub–committee for each group and the members will assume responsibility for the group.
• A workgroup member suggested adding MAXIMUS and CFEEC to the list of those to be included in training initiatives.
• A workgroup member suggested another potential training audience should be UAS assessors.
• The Department advised the workgroup that the first group of trainees will be participants and family members. The Department suggested starting with one large meeting to discuss all audiences and potential issues then break out into smaller training workgroups/sub–committees. The next Transition Workgroup meeting will focus on this. The Department will send an invitation to all workgroup members.
• A workgroup member expressed concern that Managed Care entities do not know about waiver services and waiver providers do not know about Managed Care services.

Transition Update, Jason A. Helgerson, Medicaid Director, Office of Health Insurance Programs

• Mr. Helgerson presented:
  • Recent changes in Washington is leaving a lot unknown.
  • CMS has gone dark in regards to any new decision making.
  • There are currently 103 pending State Plan Amendments and Waiver technical changes.
  • TBI Temporary Extension expires 3/10/17; NHTD Temporary Extension expires 2/25/17.
  • The 1115 Waiver that governs the entire Managed Care program is approved for five (5) years.
  • Items still in discussion with the new Administration include: time limits for benefits for certain populations, cost sharing, mandatory drug testing, HSAs (Health Savings Account) and limits in optional benefits vs. mandatory; for example, the prescription drug benefit in Medicaid is optional.
  • Currently, there are no Trump administrators within the Department of Health and Human Services (HHS) or the Centers for Medicare and Medicaid Services (CMS). All Obama appointees have left office; therefore, there are not a lot of decision makers.
  • Until NYSDOH receives further direction from CMS, we intend to move forward with the original 1/1/18 transition date for waiver services.
• Workgroup comments and questions:
  • A workgroup member asked: What will happen if NYS moves to block grants? Mr. Helgerson responded that block grants can sometimes lead to immediate limits on State funds and sometimes the State funding remains almost the same. It depends on the states (i.e., slower or faster growing states) and the kind of block grant. In the next 2–3 years, New York may end up with less federal funding for Medicaid. Medicaid works by matching money (federal and State). For example, Mississippi and Alabama get .83 cents for every dollar and New York gets .50.
  • A workgroup member asked: When the UAS studies come out, is the Department committed to making the recommended changes?
    Mr. Helgerson responded yes.
  • A workgroup member asked: What happens if the amendment to the 1115 waiver to include TBI & NHTD populations is not approved? Can HCBS services even move to MLTC? Mr. Helgerson responded that the Department has received approval from CMS in regards to moving all populations into Managed Care. Additional amendments to the 1115 (Target Case Management vs. Health Homes) may be considered in the future.
  • A workgroup member expressed concern that some timeframes have not been met on the timeline and in looking at the FAQ document distributed today, there are a lot of issues that are still not resolved. Mr. Helgerson suggested flagging any outstanding issues. A workgroup member expressed concern that there are 6 or 7 core issues not resolved that could impact people´s access to services. Mr. Helgerson requested that these 6 or 7 issues be presented to the Department in writing, then the Department will provide written comments within two (2) weeks.
  • A workgroup member expressed concern that waiver providers have not received any rate increases. Mr. Helgerson responded that providers received a retroactive rate increase in 2015 when an agreement was reached to transition to Managed Care. A workgroup member expressed a concern that since the time of that increase, costs have gone up. Mr. Helgerson responded that there is $225 million in the State budget available to providers in Medicaid for salary and rate issues, and a separate discussion should occur.
  • The Department reviewed the unresolved core issues:
    • UAS – Currently waiting for the InterRAI audit and Michigan study results;
    • Continuity of Care – 2 years, contracting with existing providers and patient choice;
    • Service Coordination issue – Need guidance from CMS on conflict– free; and
    • Role of the RRDCs in the Managed Care system – Suggestions are welcome prior to writing the RFA.
  • Mr. Helgerson requested the workgroup put all outstanding issues in writing to the Department.
  • A workgroup member expressed concern that one of the biggest outstanding issues is CFCO and requested to participate in the D&I Council (Development & Implementation Council) when it reconvenes.
  • A workgroup member asked what would happen if the 1115 waiver is terminated. Mr. Helgerson responded that if the waiver goes away, discussions will need to take place in regards to the people who will remain Medicaid eligible and therefore be eligible for the full array of State Plan Services.

Updates, Raina Josberger, NYS Department of Health, Office of Quality and Patient Safety

• Ms. Josberger presented:
  • IPRO external quality review agent completed the UAS audit of 900 records collected from the RRDCs. The report is under review and will be made public once complete.
  • The InterRAI brain injury workgroup is putting together their findings and someone will be at the next Transition Workgroup to discuss.
  • A workgroup member asked if the UAS algorithm will be reviewed. Ms. Josberger responded that the audit must be reviewed first. The Community Health Assessments for individuals with a TBI and LOC score of less than 5 are being reviewed.
  • A workgroup member asked if participants are at risk of losing waiver eligibility due to this audit. Ms. Josberger responded no, the audit did not look at people, just data.
  • A workgroup member asked how many out of the 900 triggered a Mental Health Assessment. Ms. Josberger responded that it is unknown for TBI, but generally about 40% would trigger a Mental Health Assessment on the MLTC side.
  • A workgroup member expressed concerns about why a tool was released for use without assessing cognitive or physical issues and a 3–day span is not long enough for measurement. The Department responded that the purpose of the IPRO and InterRAI audits is to measure the effectiveness of the UAS and the Department will make the suggested changes to the tool. Ms. Josberger responded that InterRAI, the developer of the tool, came up with the 3–day look back period and it is part of their standardization of the tool.

Review Frequently Asked Questions – "Questions generated from responses to the NHTD/TBI Waiver Transition Plan November 16, 2016"

• A workgroup member asked if everyone can see all the public comments received. The Department responded no, as it was not made known to people when they made comments that they would be made public.
• A workgroup member suggested NYSDOH consider other service options for the NHTD/TBI populations such as value–based.
• The workgroup put together a list of unresolved core issues:
  1. CFCO – How does this population navigate through the system to receive the five (5) services carved out? A workgroup member requested an eligibility crosswalk (i.e., level of care, spenddown, dually eligible);
  2. Tracking participants in the future;
  3. Possibility of using high needs rate cells. The Department responded that CMS has said no to this in the past;
  4. Conflict free service coordination;
  5. Qualifications of staff; and
  6. Look at service provisions/limits that were used in Behavioral Health vs. Mental Health. The Department responded that this would not be a function of the Transition Workgroup and MLTC has previously explained model contract language.

Open Discussion – Questions and Comments

• A workgroup member suggested having a separate meeting to review the results of the UAS studies/audit.
• A workgroup member asked for clarification of the PCA qualifications. The Department responded that the current Structured Day Program (SDP) staff qualifications are a one–time 40–hour PCA training. The Department requested that this question be sent to the BML for further discussion.

Meeting Wrap up

• The workgroup will provide the Department with a written summary of outstanding key issues and the Department will provide a written response.
• A separate meeting will be scheduled to discuss training curricula.
• A separate meeting will be scheduled to review the UAS audit results.
• The Department will capture questions from workgroup members who called in to the meeting and respond to those questions on the Transition webpage.

Meeting was adjourned at 12:30 pm.