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Page 1 Medicaid Managed Care Program Changes and Future Initiatives April 27, 2011 NYAPRS 7 th Annual Executive Seminar on System Transformation.

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Presentation on theme: "Page 1 Medicaid Managed Care Program Changes and Future Initiatives April 27, 2011 NYAPRS 7 th Annual Executive Seminar on System Transformation."— Presentation transcript:

1 page 1 Medicaid Managed Care Program Changes and Future Initiatives April 27, 2011 NYAPRS 7 th Annual Executive Seminar on System Transformation

2 page 2 Administrative Actions Affecting Premiums Reduce Profit From 3% to 1% (Proposal #6)  Effective 4/1/11 Reduces surplus built into MMC and FHP rates  Amendment to Part 98 will be made to reduce contingent reserve requirement as it relates to MMC and FHP lines of business for 2011 and 2012, and tightens requirements for equity withdrawals Reduce Trend Factor 1.7% (Proposal #8) Effective 4/1/11  Reduces projected 4/1/11 rate increase by 1.7% by reducing trend factors for MMC and FHP

3 page 3 Eliminate Direct Marketing (Proposal #10)  Effective 4/1/11  Contract Amendment to prohibit plans from engaging in marketing activities; plans can continue to do FE  Continue working with the industry to develop the most equitable way to administer the reduction as long as target is met.

4 page 4 Bundle Pharmacy into MMC (Proposal #11)  Effective 10/1/11  Brings pharmacy benefit into MC benefit package better aligning the overall benefit package  Modest increases to existing co-pays for brand, generic, and over-the-counter medications  Will work with the industry to promote a smooth transition

5 page 5 Behavioral Health BHO & Integrated Models (Proposal #93)  Manages FFS and current “carved out” behavioral health services for all managed care enrollees  Regional BHO’s responsible for medical management and coordination of behavioral health services  Future years risk models include integrated delivery systems

6 page 6 Benefit limits/changes Effective 4/1/11 Footwear (Proposal #30) Limited to children, diabetics, or use in conjunction with a lower limb orthotic brace Compression Stockings (Proposal #42) Limited to pregnancy or treatment of open wounds only Tobacco Cessation (Proposal #55)  Expands coverage to all women (not only pregnant women) and men  6 counseling sessions within any 12 month contiguous period

7 page 7 Benefit limits/changes  Effective 9/1/11 SBIRT (Proposal #83) Expands screening, intervention, and referral to treatment for alcohol/drug use beyond the ER setting to primary health care settings  Effective 10/1/11 PT/OT & Speech (Proposal #34) Limit 20 visits in 12 month period, similar to current limits for FHP

8 page 8 Population and Benefit Expansion, Access to Services, and Consumer Rights (Proposal #1458)  Expand Managed Care Enrollment for non-dual eligibles and modify mainstream benefit package  Access to Benefits and Consumer Protections  Streamline Managed Care Eligibility Process

9 page 9 Expand Enrollment & Modify Benefit Package  Expands enrollment of many previously exempt & excluded populations over 3 years:  Year One – program ready Enroll new populations  Exclusions – Recipient Restriction  Exemptions – HIV upstate, non-SSI SPMI/SED, primary care/pregnant w/non-network provider, temp out of district, language barrier, geographic accessibility, chronic illness limit Added benefit  Personal care

10 page 10 Expand Enrollment & Modify Benefit Package  Year Two Enroll new populations  Exclusions – Infants<1200 gr., LTHHCP where capacity, RRSY adolescents, nursing home residents  Exemptions – LTHHCP look-alikes, ESRD, CIDP, homeless Added benefit  Nursing home services

11 page 11 Expand Enrollment & Modify Benefit Package  Year Three Enroll new populations  Exclusions- eligible for Medicaid buy-in for Working Disabled, residents of State operated psychiatric centers*, blind or disabled children living apart from parents for 30 days or more, institutional foster care children*  Exemptions- residents of ICF/MR or ICF/DD and persons with needs similar to these residents, Nursing Home Diversion and transition waiver, resident of Long Term Chemical Dependence programs*, Bridges to Health foster care waiver program*, non-institutionalized foster care children, Medicaid Home and Community-based Services Waiver recipients and individuals with needs similar to the waiver recipients, Care at Home recipients and individuals with needs similar to Care at Home recipients *enrollment contingent upon decisions regarding the benefit package

12 page 12 Access to Benefits and Consumer Protections  Builds on current policies/procedures in place  Ensure adequate information for more chronic populations being enrolled How to access services How to navigate managed care systems  Ensure plans have active language translation, including TTY/TTD  Compliance with ADA  Ensure MCOs & providers are adequately trained in covered benefits (ex. DME) & consistent w/ FFS  Modify Benefit Denial notices

13 page 13 Streamline Managed Care Enrollment Process  Mandates earlier choice of managed care plan during the eligibility process For new applications  Choice must be made during the application process  Similar to enrollment process for FHPlus For persons newly targeted for mandatory enrollment  allows for 30 days to choose plan  If plan not chosen, current auto assignment algorithm followed

14 page 14 Accelerate State Assumption of Medicaid Program (Proposal #141)  November 2010 Report to Governor for State takeover of Medicaid Administrative Functions Consolidate health plan contracts for Medicaid Managed Care statewide LDSS no longer to be involved in enrolling eligibles into Managed Long Term Care plans

15 page 15 Mandatory Enrollment in MLTC and other Care Coordination Models (Proposal #90)  Mandatory Enrollment Begins – April 2012  Elimination of NH Certifiable Requirement  Elimination of Designation Requirement  Provision for MLTC Partial Cap Expansion  Health Home Conversion  Establish Workgroup

16 page 16 Mandatory Initiative for April 2012  1115 Waiver approval needed from CMS  Require all dual eligibles who need community- based long term care services for more than 120 days to enroll in Managed Long Term Care or other approved care coordination models.  Elimination of Nursing Home Level of Care Requirement upon Enrollment Impact on Partials, MAP, PACE Establish Documentation Requirements  Model Contract Amendments  MLTC and Care Coordination Model

17 page 17 Modify Role of LDSS in MLTC Enrollment (Proposal #141)  MLTC Enrollment Criteria remains the same until April 2012  Pre Enrollment Approval by LDSS will be phased out for Partial Cap and MAP by Sept, 2011 Applicability to PACE will be explored with CMS  Model Contract Amendment Required  Revisions to plan materials must be processed  Training of Enrollment Broker/other Local Entities

18 page 18 Dual Eligible Initiative (Proposal #101)  Anticipate receipt of 18 month planning contract with CMS for “State Demonstrations to Integrate Care for Dual Eligible Individuals”  Conduct analysis of Medicare / Medicaid data on Duals  Engage Stakeholders  Develop Demonstration Proposal and submit to CMS for implementation in Year 3

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