September 18, 2013

Care Management for All: The impact on

Long Term Care Providers

Webcast presented by:

Veronica M. Bencivenga, CPA Director, HMM Consulting

Complimentary Webinar sponsored by:

2

Today’s Agenda…

Understanding “Care Management for All” and the progress to date

Impact of managed care transition on long term care providers daily operations

Resources to monitor status of MRT initiatives

The Problem

Soaring Cost of Healthcare • The US spends 16% of it’s GDP on healthcare –

nearly double all other countries – Schoolhouse Rock! Tyrannosaurus Debt

• New York spends, per recipient, nearly double the nation average

• Not reflected in quality – ranked 50th in hospitalizations

• Unless spending is contained, the New York Medicaid Program will no longer be sustainable

www.health.ny.gov/health_care/medicaid/redesign/docs/mrtfinalreport.pdf

3

4

•Fee for Service Credit Card –Medicaid and traditional Medicare –Patient uses any provider –Care not coordinated, duplicative services

•Managed Care Gift Card –Costs are predictable –Services and specialists are coordinated

based on comprehensive plan of care

The Problem

5

The Solution

2008-2010 : National healthcare debate

2008 : Triple Aim • Originally developed by the Institute for Healthcare

Improvement (IHI) • a framework that describes an approach to

optimizing health system performance • adopted by CMS

2010 : Patient Protection and Affordable Care Act (ACA) signed into law March 23, 2010

6

Redesigning Medicaid

http://www.health.ny.gov/health_care/medicaid/redesign/

7

Redesigning Medicaid

http://www.health.ny.gov/health_care/medicaid/redesign/docs/mrtfinalreport.pdf

• Executive Order #5 created the New York Medicaid Redesign Team (MRT) January 5, 2011

• First report with findings and recommendations due by March 1, 2011 (only 60 days) to save money starting with SFY 2011-2012

• Identified 79 program changes and new initiatives to be deployed in 3 phases over 5 years

• NY adopts CMS’s “Triple Aim” vision for health care system redesign, delivery, and payment reform : better health, better care, lowers costs

8

Aim #1 Improving Care

• Care Management for All

• Ensure Universal Access to High Quality Primary Care

• Health Homes • Health Care

Workforce for the 21st Century

• Interoperable EHR for All New Yorkers

• Improving Behavioral Health

Redesigning Medicaid

http://www.health.ny.gov/health_care/medicaid/redesign/docs/mrtfinalreport.pdf

Aim #2 Improving Health

• Eliminating Health Disparities

• Affordable and Supportive Housing

• Redesigning New York’s Medicaid Benefit

Aim #3 Reducing Costs

• Global Medicaid Spending Cap

• Strengthening and Transforming the Health Care Safety Net

• Payment Reform • Medical Malpractice

Reform • Redefining the

State/Local Relationship in Medicaid

9

Care Management For All

Source: http://www.health.ny.gov/health_care/medicaid/redesign/docs/care_manage_for_all.pdf

Care Management for All Goals: • Transition virtually all Medicaid patient populations to

care management by April 2016 • 5 year plan started SFY 2011/2012 by NYS DOH • Improve benefit coordination, quality of care, and

patient outcomes (better care, better health, lower costs)

• Redirect Medicaid spending from fee-for-service to capitation

• Ability to expand coverage and eligibility to more New Yorkers

10

Care Management For All

11

Care Management For All 1980’s

Managed Care A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet a consumer’s health needs through communication and available resources to promote high quality, cost-effective outcomes.

VS.

Any arrangement for health care in which an organization has administrative control over primary health care services to eliminate redundant facilities and services and to reduce costs. Health education and preventive medicine are emphasized.

2010

Care Management

12

Care Management For All

Drink the

Kool-aid!

13

FIDA Demonstration Update

• A key step in the move to “care management for all” • 8/26/13 CMS approved NY participation FIDA

demonstration program

Fully Integrated Dual Advantage (FIDA)

14

FIDA Demonstration Update Highlights: • All plans will be Medicaid Managed Long Term

Care plans (MLTC’s) that modify offerings to include Medicare services (Carve-in’s).

• Dual enrollees requiring facility-based long-term services and supports are eligible for the demonstration

• “Conversion in place” enrollment-Medicare benefit will be added to their managed care plan’s portfolio

• Beneficiaries can “opt out” of the demonstration at any time.

• Region 1-NYC, Westchester, Nassau, Suffolk • Affects approximately 120,000

15

FIDA Demonstration Update Proposed Covered Benefits: • Use the NY Medicaid definition of medical

necessity for all services. • Covered Services include services covered by the

existing Medicare and Medicaid programs in New York in addition to Home and Community-Based waiver services.

• FIDA plans will have discretion to supplement covered services with non-covered services or items where so doing would address a Participant’s needs, as specified in the Participant’s Person-Centered Service Plan.

Source: Medicaid Redesign Team Update and Next Steps , FAE Health Care Conference September 9, 2013 Jason A. Helgerson, Medicaid Director NYS Department of Health

16

FIDA Demonstration Update Two Types of Plans:

Primary FIDA – Dual eligibles, age 21 and over that require community-based long term care services for more than 120 days who are not residents of an OMH facility, and who are not receiving services from the OPWDD system.

•Geographic Service Area: Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk and Westchester Counties

OPWDD FIDA – Dual eligibles, age 21 and over, who are not residents of an OMH facility, and who are receiving services from the OPWDD system

•Geographic Service Area: Statewide

Source: Medicaid Redesign Team Update and Next Steps , FAE Health Care Conference September 9, 2013 Jason A. Helgerson, Medicaid Director NYS Department of Health

17

Duals receiving community-based long-term services and supports (LTSS)

• July 1, 2014 - Voluntary enrollment (opt in) • September 1, 2014 – Passive enrollment of

eligible beneficiaries who have not made a choice to opt in or out

Duals in Nursing Homes: • October 1, 2014 - Voluntary enrollment (opt in) • January 1, 2015 - Passive enrollment of

eligible beneficiaries who have not made a choice to opt in or out

FIDA Demonstration Update FIDA Timeline:

18

Medicaid payments = Vital revenue How will the state share MRT savings with providers?

Option #1 - “Global” Shared Savings • State captures shared savings by lowering managed care

payments as costs decline. • State then devises mechanisms to make either direct

payments to providers or to require payments through managed care plans.

• Payments could be linked to both performance measures and to ensuring financial survival for vital access providers.

Source: Medicaid Redesign Team Update and Next Steps , FAE Health Care Conference September 9, 2013 Jason A. Helgerson, Medicaid Director NYS Department of Health

FIDA Demonstration Update

19

Medicaid payments = Vital revenue How will the state share MRT savings with providers?

Option #2 - Managed Care Shared Savings • Require managed care organizations to develop plans for

shared savings with their provider networks. • The state would approve all plan shared savings agreements

and ensure those agreements are enforced. • Plans would be free to use “back end” shared savings

agreements, sub-capitation and performance bonus payments as vehicles for sharing savings with providers.

• Model will be tested in the FIDA demonstration.

Source: Medicaid Redesign Team Update and Next Steps , FAE Health Care Conference September 9, 2013 Jason A. Helgerson, Medicaid Director NYS Department of Health

FIDA Demonstration Update

20

Impact on Providers

Innovation

or

Devastation

YOU decide!

Contract Negotiation

Admission and Discharge practices

Case Management – skilled staff required!

Revenue Cycle Management

Internal Communications

21

Agenda Impact on Providers

22

Impact on Providers Contract Negotiation • Know your strengths and be able to demonstrate

(QUANITFY) them: • 5 Star rating (what it is and why, back story) • Average LOS • Hospital readmission statistics • Staffing (NP or PA, Wound care nurse, etc.) • Special services (i.e., Diabetes management

training for patient and family, bariatric, memory impaired)

• Rates – Don’t ask, don’t get • NYS Assessment • Acuity Adjustment/Risk Sharing

23

Impact on Providers Sample Master Insurance Schedule

ABC Nursing and Rehab FacilityRevised: 6/27/13

Manage Care Plans: Products: Level 1 Level 2 Level 3 Level 4 Level 5 NotesRevenue Codes 190, 191, 199 192 193 194 195HIP & Magnacare 121, 128, 110 148 158 138

ALL INSURANCE PLANS Out of Network-All-Mcr/Mcd/HMO/PPO etc $325 $425 $525 $625 $725 Or at Medicare Rate - MDS Rate

Aetna All-MCR/MCD/HMO/PPO/EPO etc $240 $240 $340 $340 N/A Rate increase requested…..Currently being reviewed

Affinity Health Plan Medicaid $255 $330 $360 $650 N/A Rate increase received…Effective date 04/01/2013

Affinity Health Plan Medicare Rate increase received…Effective date 04/01/2013

Amerigroup/Healthplus Medicare 400 400 400 400 N/A One Flat Rate……Effective date 11/12/2012

Amerigroup/Healthplus Medicaid 250 $250 $250 $250 N/A One Flat Rate……Effective date 11/12/2012

Cigna All-MCR/MCD/HMO/PPO/EPO etc $375 $475 $575 $650 N/A

EasyChoice/Atlantis Medicare/Medicaid Not Contracted - Contract Request sent…Should be receiving contract in a month

Elderplan Medicare/Medicaid $330 $430 $530 $600 New contract….Effective date 03/05/2013

Elderplan MLTC Program New contract….Effective date 03/05/2013

Empire BC/BS/Wellpoint All-MCR/MCD/HMO/PPO/EPO etc 300 475 575 575 N/A New Rates…Effective date 12/01/2012

Fidelis Care of NY Medicare/Medicaid 225 $275 $325 $400 N/A New contract….Effective date 03/21/2013

GHI Commercial/HMO/PPO/EPO/POS 325 425 550 N/A N/ANo Level 4, reserve for Vent patients..New Rates effective date 10/01/2012

GHI Medicare/No Medicaid Program 310 $375 425 N/A N/ANo Level 4, reserve for Vent patients..New Rates effective date 10/01/2012

Guildnet Medicaid Not Contracted. Will be receiving paper work soon.

Healthcare Partners MedicareNot Contracted. Will be submitting paper work for their review.

HealthNet Medicare $240 + qpd $315 + qpd $400 + qpd $510 + qpd Quality Product Distribution

Levels of Care

100% Medicare RUGS score

100% Medicaid Rate

24

Summary of Covered Services

•Source: “Managing Long Term Care Services for Dual Eligibles”, Patrick J Roohan, New York State Department of Health, September 27, 2010

MLTC-P MAP PACECare management X X XHome nursing X X XHome health aides X X XPersonal care X X XNutrition services X X XAdult day health care X X XMedical social services X X XNon-emergency transportation X X XDurable medical equipment X X XPersonal emergency response system X X XPhysical, occupational, respiratory, and speech therapy X X XNursing home care X X XPhysician care X XInpatient hospital care X XOutpatient hospital care X XLaboratory/Radiology services X XDialysis X XMental health, substance abuse, and OPWDD services X XPrescription drugs X XEmergency transportation X X

25

Impact on Providers Admissions Practices • Benefit verification (on-line and by phone) • Authorizations (level, timeframe) • Family education (benefits counseling)

Discharge Practices • Change perception of who is dischargeable • Discharge begins on admission • Work with insurer on target discharge date

• Not under your control anymore

• Discharge planning more involved • Coordinating with multiple insurers to identify approved

providers

26

Impact on Providers Case Management • Dedicated resources • Experienced/Certified

• Nurse - Care Manager Certified (CMC) ,Certified Case Manager (CCM)

• Social Worker - Certified Advanced Social Work Case Manager (C-ASWCM), Certified Social Work Case Manager (C-SWCM)

(http://www.caremanager.org/why-care-management/certification-professional-conduct)

• Proactive • Excellent communication skills (documentation

comes from your EMR) • Work with Business Office and Administration to

identify and resolve payment issues timely

27

Impact on Providers Revenue Cycle Management • Cash Flow

• Bill on day of, or day after, discharge • Weekly billing all payers

• Billing practices • Claims Management Software • Clearing house (Emdeon, ePremis, Optum)

• Collections • Will spend more time to collect same or less

money

28

Impact on Providers Communication • Staff

• Interdisiplinary • Real-time

• Families • Educate about plans, benefits (or lack of), and

who is paying when • Difference between your decisions and the

insurers (discharge date, services authorized) • Vendors

• Patient payers, plans, who to bill

29

Resources

Medicaid Redesign Team: http://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm

CMS approves NY FIDA 8/26/13. See MOU fact sheet at: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-

Sheets-Items/2013-08-26.html WNY Law Center:

http://www.wnylc.com/health/entry/114/#exclusion Managed Long Term Care Plan Directory:

http://www.health.ny.gov/health_care/managed_care/mltc/mltcplans.htm Managed Care Organization Directory:

http://www.health.ny.gov/health_care/managed_care/mcplans.htm

Additional information on the transition to Managed Care for LTC providers in New York can be found at:

30

Questions?

?

Thank you.

31

Veronica M. Bencivenga, CPA Office (631)265-6289 Cell (631)880-2882 VBencivenga@horanmm.com www.horanmm.com

HMM Consulting a Division of Horan, Martello, Morrone P.C.