Matrix: MRT Phase 2 Proposals Included in 2012-13 Enacted Budget Proposal

No. Initiative Effective Date Art VII 2012-2013 Impact 2013-2014 Impact Comments/Rationale
Yes/No Gross State Gross State
Affordable Housing
1. Supportive Housing Funding Flexibility Apr-12 Yes $0.00 $0.00 $0.00 $0.00 A portion of the $75 million in the SFY 2012-13 MRT funding allocation plan may be transferred to OMH, OPWDD, OTDA and HCR for distribution through HHAP, OMH programs, Housing Trust Fund and tax-exempt bond programs. Benefits -- A supportive housing program targeted to heavy Medicaid users is likely to return the greatest savings to the state, local and federal governments in terms of reduced hospitalizations, reduced lengths of stay in long term care facilities, and unnecessary Emergency Room visits as well as improved outcomes from supportive services provided in stable, affordable housing.
2. Assisted Living Program Reform Apr-12 Yes $0.00 $0.00 $0.00 $0.00 Statutory, regulatory and/or contractual changes needed in order to reflect the Affordable Housing Workgroup recommendations. Changes include: 1.) Allow RNs to conduct assessments to determine initial and ongoing clinical eligibility for ALP services; 2.) Receive additional MA reimbursement for pre-admission assessments; 3.) Expedite enrollment by conducting post-admission audits to ensure appropriate admissions; 4.) Repeal the SS law that requires a reduction in nursing home beds to create new ALP beds, but maintain the expansion of the ALP; 5.) Lift the moratorium on CHHAs to enable ALPs to serve their residents; 6.) Allow ALPs the option to utilize their LHCSA home health aides to perform all functions within their scope of practice/tasks; 7.) Enable the ALP to contract with more than one CHHA or LTHHCP; 8.) Allow ALPs to access Medicare-covered therapy services from providers other than CHHAs or LTHHCPs; 9.) Improve the ALP survey process; and 10.) Develop a forum to revisit the ALP program in one year to evaluate implementation of these reforms and determine what more change is needed. Benefits -- New York's Medicaid-funded Assisted Living Program allows many individuals to remain in community settings with appropriate supports rather than in a more restrictive institutional setting. However, modernizing the program, which began in 1991, would allow the state to expand the number of beds available and make the provision of supports and services to ALP residents more effective and efficient.
Totals       $0.00 $0.00 $0.00 $0.00
Basic Benefit Review
3. Podiatry for Diabetics - Expand coverage of podiatry services to include private office podiatrists for adults with diabetes mellitus Apr-12 Yes −$4.40 −$2.20 −$4.40 −$2.20 Currently, MA covers the services of private practicing podiatrists only for children up to age 21 and for Medicare/Medicaid dually eligible recipients. Adults (age 21+) may obtain podiatry services in Article 28 hospital outpatient departments and free-standing clinics. Under this proposal, Medicaid will permit adult MA recipients who have a diagnosis of Diabetes Mellitus to obtain care from a private practicing podiatrist. Benefits -- Studies show that routine foot care/examination in diabetic patients can identify risk factors predictive of diabetic complications. Expanding podiatry coverage for adult diabetics will result in cost saving to Medicaid by decreasing the diabetic complications.
4. Knee Arthroscopy - Eliminate coverage of arthroscopy of the knee for osteoarthritis Apr-12 No −$0.40 −$0.20 −$0.40 −$0.20 This proposal would limit coverage for arthroscopic knee surgery when primary diagnosis is osteoarthritis of the knee (without mechanical destruction of the knee). Many patients with joint space narrowing are older with multiple medical comorbidities. Such patients are more prone to complications and, consistent with the recommendations of the American Academy of Orthopedic Surgeons ( AAOS ), there is no proven clinical benefit to arthroscopy of the knee for osteoarthritis (in the absence of mechanical destruction of the knee joint). Benefits -- 1.) Savings created by limiting arthroscopies to only those patients for whom there is medical necessity and anticipated benefit post-procedure; and 2.) Reduce medically unnecessary surgeries and potential for complications in medically complex patients.
5. Back Pain Treatments - Eliminate payment for treatments for low back pain where there is no evidence of benefit Apr-12 No −$7.70 −$3.85 −$7.70 −$3.85 This proposal would limit/exclude coverage of prolotherapy, intradiscal steroid injections, facet joint steroid injections, systemic corticosteroids and traction (continuous or intermittent) for lower back pain. Based on the current literature, intradiscal steroids offer limited clinical improvement in pain or function for patients with discogenic low back pain. Controlled trials have revealed minimal if any benefit. Benefits -- 1.) Increased savings by limiting coverage of non-evidence based treatments for low back pain; and 2.) Improved patient safety by limiting exposure to invasive procedures which can cause infections, steroid-related problems, and stretch injuries among others.
6. Breastfeeding Support - Payment for specially trained lactation consultants Apr-12 Yes −$8.40 −$4.20 −$8.40 −$4.20 Provide Medicaid reimbursement for International Board Certified Lactation Consultant (IBCLC) services for eligible pregnant women. The United States Preventive Services Task Force (USPSTF) recommends interventions during pregnancy and after birth to promote and support breastfeeding. Additionally, American College of Obstetricians and Gynecologists (ACOG) guidelines promote exclusive breastfeeding for the first six months of life. In accordance with ACOG, practitioners are directed to provide counseling and education regarding infant feeding choices with the woman during prenatal visits and immediately postpartum. Benefits -- Improved health outcomes for breast-fed babies and improved outcomes for the mother.
7. PCI (Angioplasty) - Eliminate coverage of Percutaneous Coronary Intervention ( PCI) in circumstance of no clear benefit Apr-12 No −$2.90 −$1.45 −$2.90 −$1.45 Limit coverage for PCI to only those patients who are appropriate for the procedure based on American College of Cardiology / American Heart Association (ACC/AHA) appropriateness criteria. PCI is very ef fective for evolving heart attacks, but its value is less certain for patients with stable coronary artery disease (no recent heart attack or unstable angina). Studies have shown that for many people with stable coronary artery disease, coronary angioplasty is no better than optimal medical therapy at preventing future heart attacks or strokes, nor does it extend life. Benefits -- Increased savings and decreased risk of complications by limiting coronary angioplasty to only those patients for whom there is clearly established medical necessity based on national guidelines.
8. Elective Delivery - Reduce payments for elective Cesarean sections and inductions performed < 39 weeks without medical indication Apr-12 No −$5.00 −$2.50 −$5.00 −$2.50 Do not cover elective C-section deliveries or elective induction of labor less than 39 weeks unless a documented medical indication is present. Infants delivered prior to 39 weeks have an increased chance of complications and double the mortality rate of infants delivered at full-term. Further, maternal complications may increase in cesarean section deliveries. Benefits -- 1.) Avoidance of a pre-term delivery if due date calculation is inaccurate; 2.) Avoidance of health risks to mother and newborn; 3.) Reduction of NICU admissions; 4.) Reduced length of hospital stays; 5.) Reduced risk of neonatal respiratory problems; and 6.) Decreased incidence of primary C-section rates will result in a decrease in repeat C-section (and associated costs) for future births.
9. Growth Hormone - Eliminate coverage for treatment of Idiopathic Short Stature (ISS) with growth hormone Apr-12 No −$10.00 −$5.00 −$10.00 −$5.00 Limit coverage of growth hormone injections for idiopathic short stature in children. Idiopathic Short Stature (ISS) is not considered to be a disease, but a term used to describe children two or more standard deviations below the mean for their age and gender and for who no alternate diagnosis can be made to account for this height. Insurance plans exclude coverage of growth hormones for short stature caused by heredity and not caused by a diagnosed medical condition. Coverage will remain available in cases of documented growth hormone deficiency. Benefits -- Considerable Medicaid cost savings will be realized and Medicaid policy will mirror that employed by other payers.
Totals       −$38.80 −$19.40 −$38.80 −$19.40
Health Disparities
10. Implement and Expand Data Collection/Metrics To Measure Disparities Apr-12 No $2.00 $1.00 $2.00 $1.00 Implement and expand on data collection standards required by Section 4302 of the Affordable Care Act by including detailed reporting on race and ethnicity, gender identity, the six disability questions used in the 2011 American Community Survey (ACS), and housing status. In addition provide funding to support data analyses and research to facilitate SDOH work with internal and external partners to promote programs and policies that address health disparities, improve quality and promote appropriate and effective utilization of services including the integration and analysis of data to better identify, understand and address health disparities.
11. Improve Language Access to Address Disparities Apr-12 No $2.70 $1.35 $2.70 $1.35 Amend Medical Assistance rates of payment for hospital inpatient and outpatient departments, hospital emergency Departments, diagnostic & treatment centers, and federally-qualified health centers to provide reimbursement for the costs of interpretation services for patients with limited English Proficiency (LEP) and communication services for people who are deaf and hard of hearing.
12. Promote Language Accessible Prescriptions: Apr-12 Yes $0.00 $0.00 $0.00 $0.00 Require all chain pharmacies to provide translation and interpretation services for Limited English Proficient (LEP) patients, that standardized prescription labels be required to ensure understanding and comprehension especially by LEP individuals and that prescription pads be modified to allow prescribers to indicate if a patient is LEP, and if so, to note their preferred language.
13. Expand Services to Promote Maternal and Child Health Apr-12 Yes $5.00 $2.50 $5.00 $2.50 Utilize Medicaid to promote maternal and child health including support of initiatives to demonstrate effective and efficient use of Health Information technology to improve coordination of care.
14. Promote Hepatitis C Care and Treatment Apr-12 Yes $2.10 $1.05 $2.10 $1.05 Promote Hepatitis C care coordination and integration through the provision of services which may include client outreach, identification and recruitment, hepatitis C education and counseling, coordination of care and adherence to treatment, assistance in obtaining appropriate entitlement services, peer support and other supportive services as needed and authorized.
15. Promote Medicaid Coverage of Harm Reduction Activities Apr-12 Yes $0.41 $0.21 −$11.25 −$5.62 Authorizes Medicaid reimbursement for harm reduction counseling and services at community-based and clinical provider sites to reduce or minimize the adverse health consequences associated with drug use.
Totals       $12.21 $6.11 $0.55 $0.28
Health Systems Redesign
16. Brooklyn Apr-12 Yes $0.00 $0.00 $0.00 $0.00 The Budget provides for continued investment through HEAL and Medicaid to support provider system transformation, either through merger, closure, acquisition or restructuring. In addition, it provides the Commissioner the ability to assist in management and governance of facilities should the situation warrant it. This initiative is supported by the Essential Community Provider Network and Vital Access Providers proposal below.
Totals       $0.00 $0.00 $0.00 $0.00
Managed Long Term Care
17. Fair Hearing Reform Investments Apr-12 No $0.50 $0.50 $0.50 $0.50 A targeted increase in resources to handle the move to mandatory enrollment in managed long term care or other care coordination models. Providers should receive notice of fair hearings requested by their clients. Ongoing training for ALJs pertaining to state law, rules, and regulations should be evaluated. Consumers and plans should have input and access to the training. Benefits -- Improved fair hearing process.
Totals       $0.50 $0.50 $0.50 $0.50
Payment Reform & Quality Measurement
18. Essential Community Provider Network and Vital Access Providers Apr-12 No $86.40 $43.20 $100.00 $50.00 Two initiatives are being recommended -- Essential Community Provider Network (short-term funding) and Vital Access Providers (ongoing rate enhancement or other support) - to ensure access to care for patients. New York State will assume an active role in ensuring certain essential community providers (hospitals, nursing homes, D&TCs or home health providers) be eligible to receive short-term funding to achieve defined operational goals such as a facility closure, merger, integration or reconfiguration of services. After collaborating with the members of the Medicaid Redesign Team Health Systems Redesign: Brooklyn Work Group, this measure has the potential to be a useful tool and could be used in concert with HEAL/FSHRP funding in the reconfiguration and rightsizing of the Brooklyn health care system and be consistent with previously endorsed Medicaid Redesign Team recommendations (i.e., MRT #67: Assist Preservation of Essential Safety-Net Hospitals, Nursing Homes and D&TCs). Benefits -- This recommendation will ensure continued access to vital health care services for the uninsured, Medicaid, and other vulnerable populations during a period in which the health care system is experiencing significant restructuring and payment reform. VAP funds coupled with HEAL/FSHRP reserves of up to $450 million provide a sufficient funding source to ensure the smooth transition of service within communities and to provide reinvestment capital for new investment paradigms.
Totals       $86.40 $43.20 $100.00 $50.00
Program Streamlining and State/Local Responsibilities
19. Modernize and automate eligibility system Ongoing No $20.00 $2.00 $30.00 $3.00 New York must have one eligibility determination and enrollment system for its Medicaid program and all Medicaid-eligible sub-populations (i.e., over 65, non-MAGI, under 65, MAGI, those who need health care services, those who need long term care services). The new system should support eligibility determinations and enrollment for all health and human service programs. Benefits -- A modern, fully automated eligibility system will allow the State to meet the IT requirements of the ACA. It will also improve the efficiency and accuracy of eligibility determinations.
20. Asset Verification System Procurement Oct-12 No $2.00 $1.00 $4.00 $2.00 Invest in an Asset Verification System (AVS) to permit the electronic verification of assets (including assets in the 5 year look back period) for determining eligibility for aged, blind, and disabled Medicaid applicants and recipients.
21. Enrollment Assistors for Disabled applicants Oct-12 Yes $0.00 $0.00 $6.00 $3.00 Contract with one or more entities to provide assistance to elderly and disabled individuals applying for Medicaid.
22. Limit Local Medicaid Cap growth Apr-12 Yes $0.00 $0.00 $61.10 $61.10 Provide relief to local governments by reducing the growth in the local share of Medicaid expenditures for all counties and New York City. Effective April 1, 2013, the local share of growth phases down from about 3% currently to 2% in CY 2013, 1% in CY 2014, and 0% in CY 2015 and going forward. This new State funding will be allowed in addition to the 4% Global Cap.
23. Phase-in State Assumption of Local Administration and cap costs Apr-12 Yes −$28.00 −$28.00 −$68.40 −$68.40 Begin a phased-assumption of local government administration of the Medicaid program and establish a cap on State reimbursement of local governments for Medicaid administration at fiscal year 2011-12 levels. Establishes a $23 million pool for counties that exceed the cap. Centralization will permit more uniform and efficient program administration and better position the State for implementation of the Affordable Care Act.
Totals       −$6.00 −$25.00 $32.70 $0.70
Workforce Flexibility and Change of Scope of Practice
24. Primary Care Service Corps Oct-12 Yes $1.00 $0.50 $1.00 $0.50 PCSC is a service-obligated scholarship program to increase the supply of midwives, nurse practitioners and physician assistants and others who practice in underserved communities. Eligible clinicians would receive loan repayment funding in return for a commitment to practice in an underserved area. Awards would be the same as those awarded by the National Health Service Corps (NHSC) based on the amount of each individual's qualifying educational debt, but not to exceed the maximum amounts. Benefits -- 1.) May result in greater penetration of non-physician clinicians in underserved areas; 2.) State gets 50% match from federal dollars; 3.) May ease burden to primary care physicians in underserved areas ("multiplier effect"); 4.) Because a greater percentage (compared to physicians) of non-physician clinicians who graduate from New York schools remain in state and their educational debt levels are lower than those of physicians, extending loan repayment eligibility to non-physician primary care clinicians may be both cost-effective and conducive to the retention of health care personnel in underserved areas.
Totals       $1.00 $0.50 $1.00 $0.50
Additional Considerations
25. Redirect Inpatient Reform Transition II Funds to the Safety Net/VAP Pool Apr-12 No −$25.00 −$12.50 −$25.00 −$12.50 The Inpatient Reform methodology (initiated in SFY 2008-09) included two separate Transition pools to smooth the distribution of funds among hospitals. Under this proposal, rather than return Transition II funds to the base rate (as is currently planned) to be distributed to all hospitals, the funds will be dedicated towards establishing a $100M Safety Net/VAP Pool described above. Transition I funds are not available for this purpose as those funds were programmed to be returned to the Financial Plan at the end of each year of the phase-out.
26. NEW -- Delay in Supportive Housing Implementation (cash flow) Apr-12 No −$15.00 −$15.00 $0.00 $0.00 Potential cash delay associated with slower than anticipated enrollment; full $75 million appropriation remains available.
27. NEW -- Technical Avail (UPL Adjustment) Apr-12 No −$25.00 −$12.50 −$25.00 −$12.50 DOH's preliminary analysis indicates that existing outpatient rates could exceed maximum threshold amount allowed under Federal rules.
28. NEW -- Prescriber Prevails for Mental Health Drugs within Managed Care Jan-13 Yes $6.25 $3.13 $25.00 $12.50 This initiative will allow the prescriber's professional judgement to prevail for atypical antipsychotics that are not on plan formularies or require prior authorization. Plans will continue to develop formularies and administer prior authorization programs for atypical antipsychotics. However, in instances where medical necessity has not been demonstrated according to criteria established by the plan, the "prescriber will prevail" and the plan will be required to cover the drug as originally prescribed.
29. NEW -- Repeal Estate Recovery Statute     $5.20 $2.60 $5.40 $2.70 The Legislature repealed language related to estate recovery previously enacted with the 2011-12 budget.
Totals       −$53.55 −$34.28 −$19.60 −$9.80  
GRAND TOTAL $1.76 −$28.37 $76.35 $22.78