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Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared – Appendix – New York – 8426-06 « » The Henry J. Kaiser Family Foundation

Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS

New York

MOU Signed: Aug. 26, 2013
3-way contract not yet available
Demonstration Duration: 3 years
Jan. 1, 2015 to Dec. 31, 20171
Target Group: Includes:  an estimated 170,000 full benefit dual eligible beneficiaries age 21 and older in 8 counties who are eligible for a nursing home level of care and receiving facility-based LTSS or who are eligible for the nursing home transition and diversion § 1915(c) waiver or who require community-based LTSS for more than 120 days are eligible to enroll in the demonstration

dual eligible beneficiaries who reside in a state Office of Mental Health, psychiatric,  ICF/IDD, or alcohol/substance abuse long-term residential treatment facility or an assisted living program, those receiving services from the state DD system, those eligible to reside in an ICF/IDD but who choose not to, participants in the § 1915(c) DD and TBI HCBS waivers, those expected to be eligible for Medicaid for less than 6 months, those eligible only for TB-related, breast and cervical cancer or family planning expansion Medicaid services, those receiving hospice services at the time of enrollment, non-elderly individuals who are screened and require breast and cervical cancer treatment in the CDC early detection program who do not have other creditable coverage, those eligible for emergency Medicaid, and participants in the Foster Family Care demonstration
Geographic Area: 8 counties:  Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, Westchester
Enrollment: Initial enrollment period is voluntary, followed by passive enrollment periods in which the remaining beneficiaries in the target population will be automatically enrolled.

Beneficiaries receiving community-based LTSS and those in nursing facilities can voluntarily enroll in the demonstration with enrollment effective no earlier than October 2014.2  Those that do not voluntarily enroll will be passively enrolled no earlier than Jan. 1, 2015.3  The MOU’s dates for notices in advance of voluntary and passive enrollment have not yet been updated.

Passive enrollment for each group will be phased in over a minimum 4 month period.

Populations who will not be passively enrolled include Native Americans, people who are eligible for the Medicaid buy-in for working people with disabilities and who are nursing home eligible, Aliessa court ordered individuals, and enrollees in PACE, a Medicare Advantage SNP for institutionalized beneficiaries, health homes, ACOs, the Independence at Home demonstration and employer or union-sponsored coverage

Beneficiaries can opt out of the demonstration until the last day of the month prior to their effective enrollment date and at any time after enrollment.

The MOU indicates that NY will submit conforming amendments to its § 1115 Partnership Plan (MLTC) waiver and § 1915(c) nursing facility transition and diversion waiver.  NY’s § 1115 waiver requires beneficiaries in the demonstration geographic area who need 120 days of LTSS to enroll in Medicaid managed care.4

Intelligent assignment for passive enrollment will consider previous managed care enrollment and historic provider utilization
Financing: Capitated with savings percentage (1% in year one, 1.5% in year two, 3% in year three) applied upfront to baseline Medicare and Medicaid contributions, except that savings in year three will be reduced to 2.5% if at least 1/3 of plans experience losses exceeding 3% of revenue in year 1, based on at least 15 months of data; capitation rate quality withhold same as in California (1% in year 1, 2% in year 2, 3% in year 3)
Medicare baseline for capitated payments: Same as California except that Medicare Advantage risk score coding intensity adjustment factor will apply beginning in CY 20145
Medicare risk adjustment: Same as California
Medicaid baseline for capitated payments: Blend of Medicaid MLTC capitated rates that would apply to enrollees in the demonstration area and estimate of FFS costs for services excluded from MLTC rate
Medicaid risk adjustment: Rating categories6 risk adjusted similar to the model used for MLTC capitated rates
Risk sharing: Required medical loss ratio of 85%; may require plans to maintain a minimum level of reinsurance
Care Delivery Model: Fully Integrated Duals Advantage (FIDA) plans will perform assessments using the state-approved assessment tool and provide person-centered care management and integrated medical, behavioral health, substance use, and community and facility-based LTSS through Interdisciplinary Teams.  The Team makes coverage determinations and authorizes services, which may not be modified by the plan outside the Team.  Beneficiaries have the right to choose and change their care managers.
Participating Health Plans: Aetna
Catholic Managed Long Term Care, Inc. (Archcare)
Centers Plan for Healthy Living
Elderplan (Homefirst)
Fidelis Care of NY (NYS Catholic Health Plan)
Healthfirst (Managed Health, Inc.)
HHH Choices
Independence Care Systems
North Shore LIJ HealthPlan, Inc.
Senior Whole Health
United Healthcare
Village Care MAX

Participation is subject to plans meeting readiness review requirements, and the final plan announcement is expected in the second quarter of CY 2014.7
Benefits: Includes all Medicare and Medicaid services except hospice, out-of-network family planning, directly observed therapy for TB and methadone maintenance; includes § 1115 Medicaid MLTC services and § 1915(c) nursing facility diversion and transition HCBS; plans have flexibility to enhance covered services with additional non-covered services to address beneficiary needs and to cover items or services not traditionally covered by Medicare or Medicaid that are necessary and appropriate for the beneficiary
Continuity of Care: Beneficiaries must maintain current providers and service levels for at least 90 days after enrollment or until a care assessment has been completed by the FIDA plan, whichever is later, except that beneficiaries must maintain current nursing facility providers for the duration of the demonstration
Ombuds Program: NY is creating a new independent FIDA participant ombudsman to help beneficiaries access care through the demonstration, provide individual advocacy and systemic oversight, and gather and report data
Stakeholder Engagement: FIDA plans must establish at least one participant advisory committee that meets quarterly and is open to all participants and a process for the committee to provide input to the plan.  Plans must demonstrate that beneficiaries with disabilities participate in the plan governance structure.  Plans also are encouraged to include beneficiaries on their boards of directors.
Notice:  same as California (single integrated notice)

Timeframe to request initial appeal:
  same as Illinois (60 days)

Internal health plan appeal: 
same as Illinois (all initial appeals must be filed with health plan) except MOU does not mention timeframes for appeal resolution; paper review unless beneficiary requests in-person review; expedited review is available

Integrated external appeals process: all adverse internal health plan appeal decisions are automatically sent to Integrated Hearing Officer external to the plan for a phone or in-person hearing – expedited review is available; 60 days to appeal adverse Hearing Officer decision to Medicare Appeals Council for paper review; adverse Appeals Council decision can be appealed to federal district court

Appeals where Medicare and Medicaid services overlap:  same process as above – NY is establishing one integrated appeals process for all Medicare Parts A and B and Medicaid appeals

Continued benefits pending appeal:  benefits continue pending appeal during the internal health plan appeal, the Integrated Hearing Officer hearing, and Medicare Appeals Council review for all prior-approved services if the initial health plan appeal is requested within 10 days of the termination or modification notice
Medicare Part D:  same as California (existing Medicare Part D appeals process continues to apply)


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