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Medicaid Redesign in New York State Presented by Lara Kassel, Coalition Coordinator Medicaid Matters NY FamiliesUSA Health Action January 23, 2014.

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Presentation on theme: "Medicaid Redesign in New York State Presented by Lara Kassel, Coalition Coordinator Medicaid Matters NY FamiliesUSA Health Action January 23, 2014."— Presentation transcript:

1 Medicaid Redesign in New York State Presented by Lara Kassel, Coalition Coordinator Medicaid Matters NY FamiliesUSA Health Action January 23, 2014

2 2 Medicaid Matters NY Statewide coalition of over 140 organizations representing the interests of New Yorkers served by the Medicaid program Established in 2003 in response to threats to Medicaid at the state and federal levels Systems advocacy on behalf of Medicaid beneficiaries is crucially important because of the many competing interests in Albany

3 3 Changes to Medicaid in New York Expansion of Medicaid Managed Care Many other initiatives to “bend the cost curve”; just some examples: –Primary care investments –Regional planning –Benefit review Global Medicaid spending cap State takeover of administration from the counties Implementation of the Affordable Care Act

4 4 The Medicaid Redesign Team Created by Governor Cuomo in January 2011 to address the budget deficit and “bend the cost curve” New Medicaid Director had done similar process in Wisconsin Made up of provider representatives and one consumer advocate (additional added later)

5 5 The Medicaid Redesign Website

6 6 The Medicaid Redesign Team: Phase I Goal: find $2B in Medicaid savings for the 2011-2012 fiscal year and deliver recommendations to the Legislature for inclusion in the budget Public input through public hearings and Medicaid Redesign website MRT meetings and individual analysis to review the public’s suggestions, as well as those from within the Health Department MRT vote on a final package and delivery to the Legislature on February 24, 2011

7 7 The Medicaid Redesign Team: Phase II Goal: reform Medicaid to find long-range savings and efficiencies and deliver final report to Governor for the 2012-2013 Executive Budget New MRT members added in Summer 2011, including an additional consumer representative Workgroups formed to address specific issues Workgroups met and delivered recommendations to the Governor in December 2011 Some workgroup recommendations included in 2012- 2013 Executive Budget Final report issued April 2012

8 8 MRT Phase II: The Workgroups Affordable Housing Basic Benefit Review Behavioral Health Health Disparities Health Systems Redesign: Brooklyn Managed Long Term Care Medical Malpractice Reform Payment Reform and Quality Measurement Program Streamlining and State/Local Responsibilities Workforce Flexibility

9 9 Expansion of Medicaid Managed Care From a consumer perspective, the biggest change to Medicaid Over 1 million people will be new to Medicaid Managed Care in the next few years

10 10 Expansion of Medicaid Managed Care (cont’d) Various types of care management in Medicaid: Traditional/mainstream managed care Health Homes Behavioral Health Organizations (BHOs) Managed Long Term Care Fully Integrated Duals Advantage (FIDA) Developmental Disabilities Individualized Support Care Coordination Organizations (DISCOs)

11 11 Expansion of Medicaid Managed Care (cont’d) Fee-for-ServiceManaged Care Individual Services Wide provider choice; minimal limits on services; limited care coordination Provider choice limited; services limited; focus on care coordination FinancesVarying co-paysVarying co-pays and incentives Provider Services Driven by provider assessment of need, subject to review Usually determined and authorized by plan Finances State sets reimbursement, volume- driven Rate negotiated with plan, volume controlled Payer Services Scope driven by federal and state laws, regs and policy Scope driven by contract with managed care plan Finances Total paid = rate X service utilizationTotal paid = per member per month (PMPM) X number of enrollees

12 12 Medicaid Managed Care: Advocate Concerns Choice Transitions Consumer knowledge of their rights Network adequacy Plan capacity and knowledge Oversight, monitoring, and reporting Capitation incentive for reducing access

13 13 Medicaid Managed Care Ombudsman Program Independent, individual assistance services for people with disabilities or chronic illness Systems advocacy for these constituencies who are new to Medicaid Managed Care “Hub and spokes” model to provide on-the-ground assistance Statewide distribution of disability specialists and legal experts Build on success of existing programs, strengthen local capacity

14 14 MRT Waiver Amendment NYS request to amend the NY Partnership Plan (1115 waiver), the vehicle by which the state administers Medicaid Managed Care Overview document released 5/14/12; amendment request submitted to CMS 8/6/12 (with stakeholder engagement process) Five-year reinvestment of $10B in savings associated with MRT actions

15 15 MRT Waiver Program Areas 1)Primary Care Expansion 2)Health Home Development Fund 3)New Care Models 4)Expand Vital Access/Safety Net Program 5)Public Hospital Innovation 6)Medicaid Supportive Housing Expansion 7)Long Term Transformation and Integration to Managed Care 8)Capital Stabilization for Safety Net Hospitals

16 16 MRT Waiver Program Areas (cont’d) 9)Hospital Transition 10)Ensuring the Health Workforce Meets the Needs in the New Era of Health Care Reform 11)Public Health Innovation 12)Regional Health Planning 13)MRT Waiver Evaluation and Program Implementation

17 17 MRT Waiver 2.0 Early December 2013 received official notice through a webinar hosted by the Medicaid Director that the MRT Waiver Amendment application had been revised Through many months of negotiations with CMS, the MRT Waiver changed dramatically Revised application submitted to CMS mid-December without posting documents ahead of time and with little public notice, representing an about-face as far as transparency in the process

18 18 MRT Waiver 2.0 (cont’d) Request amount and duration did not change; $10 billion over five years CMS will not approve waiver for: –Capital –Rental subsidies –Regional planning –Evaluation –Health IT State contends that revised MRT Waiver honors the spirit of the original submission, intends to follow through with everything originally proposed

19 19 MRT Waiver 2.0 (cont’d) Instead consists of three main components: Delivery System Reform Incentive Payment program (DSRIP) Funding through managed care contracting Primary care technical and operational assistance Workforce needs: retraining, recruitment, retention 1915i services State plan amendment for Health Home development grants

20 20 Delivery System Reform Incentive Payment program Model employed elsewhere (TX, NJ, and KS) The bulk of MRT Waiver 2.0; $7.375 billion over five years to fund projects that will reduce avoidable hospitalizations Public hospitals and safety net providers eligible to apply for funding Menu of pre-approved project options Applications to be reviewed by panel of experts Funding allocated based on outcomes

21 21 DSRIP advocate response and concerns Applaud the level of transparency and accountability built into the proposal Panel reviewing applications must include consumer advocate representation Funding being allocated through hospitals; should be required to work with community-based organizations and front-line providers Definition of ‘safety net provider’ critically important Outcome measures very clinical in nature

22 22 Advocacy going forward MRT Waiver implementation and funding allocation Rest of MRT implementation –Medicaid Managed Care expansion –Implementation of Managed Care Ombuds Program, and other initiatives not funded through MRT Waiver –Integration of Medicaid in NYS of Health –Medicaid global spending cap

23 23 Thank you! Contact information: Lara Kassel 518-320-7100

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