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New Populations and Benefits Transitioning to Mainstream Medicaid Managed Care. Division of Health Plan Contracting and Oversight Vallencia Lloyd May 31, 2012. What Will Be Covered Today?.

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new populations and benefits transitioning to mainstream medicaid managed care

New Populations and Benefits Transitioning to Mainstream Medicaid Managed Care

Division of Health Plan Contracting and Oversight

Vallencia Lloyd

May 31, 2012

what will be covered today
What Will Be Covered Today?

New mandatory populations in SFY 2012-13 with focus on non-dually eligible persons in receipt of long term care services

New benefits transitioning into managed care

Preparation strategies to minimize disruption of care

Questions

slide3

Expand Enrollment & Modify Benefit Package

  • The Medicaid Redesign Team proposal # 1458 focus was to streamline and expand enrollment of the non-dually eligible population into Medicaid managed care, including many previously exempt & excluded populations, and to integrate benefits.
    • MRT implementation began in August, 2011
    • Initiatives will continue over the next three years
    • Expansions will occur as program features are developed
slide4

Changes to MMC Benefit Package

SFY 12-13

  • Effective 7/1/12
    • Dental for MCOs currently not providing
  • Effective 9/1/12
    • Consumer Directed Personal Assistance Program (CDPAP)
  • Effective 10/1/12
    • Orthodontia
  • These changes affect the mainstream managed care plans and HIV-SNPs

4

slide5

New Populations in SFY 12-13

  • Effective 4/1/12
  • Individuals with end stage renal disease
  • Individuals receiving services through the Chronic Illness Demonstration Program
  • Homeless persons
  • Infants born weighing under 1200 grams or disabled under 6 months of age
  • Effective 7/1/12 (contingent on CMS approval)
  • Individuals with characteristics and needs similar to those receiving services through an HCBS/TBI, HCBS/CAH, LTHHCP, or ICF/DD
  • Effective 1/1/13 (contingent on CMS approval)
  • Long Term Home Health Care Program (where capacity exists)
slide6

Population Expansion – plan readiness

  • For new populations implemented
    • SDOH reviews the care patterns of the populations and compiles provider lists
      • eg., for 4/1/12 populations - Renal disease, specialty neo-natal hospitals, homeless providers, etc.
    • Lists of providers sent to MCOs for contracting purposes to avoid care disruption
      • For LTHHCP home/personal care provider list will be developed through LTHHCP contacts
    • Providers encouraged to work with patients in choosing a plan their providers contract with
    • Transitional Care Requirements will apply
slide7

New Populations - look-alikes

  • Individuals with characteristics and needs similar to those receiving services through an HCBS/TBI, HCBS/CAH, LTHHCP, or ICF/DD
    • This does NOT include those persons that the state has pre-coded as OPWDD
    • Clients have option of applying to be in a waiver, OR applying through OPWDD for designation to remain exempt
new populations lthhcp
New Populations - LTHHCP
  • Long Term Home Health Care Program
    • Effective 1/1/13 (contingent upon CMS approval)
    • Non duals enrolled in the LTHHCP must disenroll from the LTHHCP and have three options for enrollment
      • into a MLTCP,
      • a mainstream Managed Care plan or;
      • enrollment into an exempt waiver program
    • If enrolled in another waiver (CAH, TBI, etc) may be enrolled in mainstream MMC simultaneously or remain in FFS
  • NOTE: LTHHCP disenrollment from waiver and enrollment into managed care only where capacity exists
slide11

Education and Outreach

  • Local Districts
    • Posters in community, working with community organizations, etc
  • Providers
    • NYC staff training of providers, Medicaid Update article, webinar
  • Health Homes

- State work with Health Homes to assist in selecting the right plan

slide12

Enrollment

  • Populations that self identified and were approved as exempt with NYMedicaid CHOICE will receive a notice informing them that their exemption/exclusion is going away and they have 30 days to apply for another exemption if appropriate.
  • All new mandatory populations will receive a mandatory notice advising them that it is time to choose a health plan
  • Education and enrollment processing
    • NYMedicaid CHOICE (NYMC) is the enrollment broker for the City of New York and most upstate counties
    • County DSS for non-NYMedicaid CHOICE counties
  • Statewide availability of NYMC for any recipient with questions or to enroll by calling
  • 1-800-505-5678
slide13

Mandatory Enrollment

  • Consumers who are targeted for enrollment or are eligible for enrollment upon recertification will have 30 days to choose a health plan
  • 90 day grace period
  • Lock in for 9 months unless have a good cause reason
  • Persons applying for Medicaid are required to chose a Health plan when filling out their Medicaid Application
slide14

Mandatory Packet

  • Cover letter
  • Brochure
  • Health Plan list
  • Enrollment form
  • Business reply envelope
slide15

NYS Medicaid Managed Care

05/20/12

CLINTON

Rural

FRANKLIN

Rural

ST LAWRENCE

Rural

ESSEX

Rural

JEFFERSON

Rural

LEWIS

Rural

HAMILTON

Rural

WARREN

HERKIMER

OSWEGO

WASHINGTON

ORLEANS

ONEIDA

NIAGARA

SARATOGA

MONROE

WAYNE

FULTON

Rural

ONONDAGA

GENESEE

Rural

SENECA

Rural

MONTGOMERY

Rural

ONTARIO

MADISON

SCHENECTADY

ERIE

LIVINGSTON

CAYUGA

Rural

WYOMING

Rural

YATES

Rural

OTSEGO

Rural

ALBANY

CORTLAND

Rural

RENSSELAER

CHENANGO

Rural

SCHOHARIE

TOMPKINS

SCHUYLER

Rural

STEUBEN

Rural

CATTARAUGUS

Rural

GREENE

Rural

TIOGA

CHAUTAUQUA

Rural

ALLEGANY

Rural

DELAWARE

Rural

BROOME

COLUMBIA

Rural

CHEMUNG

ULSTER

DUTCHESS

SULLIVAN

Rural

Voluntary

7

ORANGE

PUTNAM

WESTCHESTER

ROCKLAND

NASSAU

SUFFOLK

NYC

Mandatory w/o Maximus

22

Mandatory w/ Maximus

29

slide16

HOW TO MAKE THE RIGHT CHOICE?

  • The provider-client relationship is very important and consumers are encouraged to speak to their current provider and find out what plans they currently participate with.
  • If the client wishes, he/she can also call New York Medicaid CHOICE at 1-800-505-5678 who can verify what plans their provider participates with.
slide17

Assistance With Plan Choice

NYMC representatives are capable of locating a provider by entering one or more of the following characteristics to perform a search on HCS:

  • provider name or license number,
  • site name, zip code, primary designation,
  • primary specialty, or
  • language

LDSS managed care staff have plan provider information available to assist with finding a provider and plan choice

slide18

Consumer Representation

  • When a person other than the consumer contacts a local district or New York Medicaid CHOICE - verbal or written authorization from the consumer is required
  • Verbal: consumer identifies representative to the counselor
  • Written: consumer submits a letter or consent form designating a person as their representative:
        • Date, duration of request
        • Consumer CIN/SSN
        • Representative’s name, clinic or hospital association
        • Consumer’s signature
    • NOTE: Translators are not considered representatives and employees of health plans contracted by the SDOH cannot serve as representatives of consumers unless they are members of the Medicaid case
utilization review requirements
Utilization Review Requirements
  • Any entity conducting utilization review/medical management must be a registered UR agent or an article 44 MCO.
  • If MCO and conducting UR/MM, must meet Article 49 requirements and BBA requirements.
  • If the plan is delegating the function to a provider, agent, or IPA, they must be a registered UR agent.
    • Any delegation must be done via a management agreement, which must be approved by SDOH.
plan contracting requirements
Plan Contracting Requirements
  • Plans must have an adequate network.
  • Must provide for a minimum of 2 providers per county, if available.
  • Plans contract with providers directly.
  • All contracts must use the Contract Standard Clauses
  • Scope of services and reimbursement must be identified in every agreement.
  • All plans currently cover home care, pc, and short term nursing home care and must have an adequate array of providers.