Coalition’s Advocacy Letter Calls for Changes to NY Duals Program
October 22, 2013 11:49 AM
The Coalition to Protect the Rights of New York’s Dually Eligible (the Coalition) recently wrote an advocacy letter (the Letter) to the New York State Department of Health (NYSDOH) and the Centers for Medicare and Medicaid Services (CMS) requesting “a seat at the table” in upcoming contract negotiations for the Fully Integrated Duals Advantage (FIDA) program implemented in New York between CMS, NYSDOH, and the FIDA plans. The resulting contract will be based on the basic framework of the Memorandum of Understanding (MOU) signed by NYSDOH and CMS in August. The highlights of the Letter are discussed below.
More detail needed on passive enrollment. The Coalition advocated for more detail on the structure and mechanics of passive enrollment.
180-day transition period needed. The Coalition remarked that while Virginia and Illinois dual demonstration MOUs contain 180-day transition periods for allowing enrollees to maintain their current providers, New York’s MOU only allows for a 90-day transition period. The Coalition recommended a 180-day transition period, as it claimed “that the communications and processes…between plans, providers and enrollees” need more than 90 days to occur.
Conduct assessments in hospitals and rehabilitation facilities. The Coalition recommended that, for enrollees receiving temporary care in hospitals and rehabilitation facilities, the contract should mandate that FIDA Plans conduct assessments in these settings, especially to determine if home and community-based services (HCBS) are appropriate. The Coalition remarked that failing to do so in managed long term care results in enrollees seeing a delay in receipt of HCBS.
Specify care manager’s licensing and credentialing requirements. The Coalition recommended that the contract contain “specific qualifications of the care manager, including licensure and credentialing requirements and necessary training.”
Transitions to the Home and Community
Incorporate measures to further promote HCBS. The Coalition criticized the MOU for not sufficiently encouraging HCBS, as it merely promotes referral to either the Money Follows the Person (MFP) program or the Pre-Admission Screening and Resident Review (PASRR) evaluations). The Coalition recommended that the FIDA Plans take on the responsibilities of MFP contractors, determine HCBS eligibility, and find housing options for eligible enrollees. FIDA Plans should also be required to report extensively on HCBS statistics. For details, see page 4, here. Finally, FIDA Plans should receive incentives (either positive, negative, or both) to assess those institutionalized and triage those eligible to the home and community.
Create high risk pools before capitation rates. The Coalition noted that the MOU will set the Medicaid rate component based on capitated rates from Medicaid managed care. However, NYSDOH recognizes “high need cases” (i.e. those needing 24/7 community-based or split-shift care) necessitate additional “financial incentives” to the FIDA plans to avoid institutionalization. Therefore, the Coalition argued that these pools should be created before capitation rates are set for the entire program in order to insure its success.
Incorporate more protective accommodation language. The Coalition called for language in the contract to include “more concrete ADA compliance standards” for providers.
Implement state-based quality standards. The Coalition recommended a reporting system run by NYSDOH which is based on the quality withholds standards in the MOU.
Increase access. The Coalition advocates that the FIDA Plans contract with providers in areas where such services are scarce and/or provide more detailed assistance for accessing out of network care where needed.
To see the full Letter, click here. To see a previous Council brief on New York’s MOU with CMS, click here.
The National Council on Medicaid Home Care – a NAHC affiliate – offers the following analysis of the letter and its consequences:
Passive Enrollment Process. The Council agrees that there should be greater clarity regarding the methodology of passive enrollment. The Council would appreciate further detail on how continuity of care and consumer protections will be preserved with this model.
Transition Period.The Council agrees that a 180-day transition period would be preferred over a 90-day transition period. The Council has previously petitioned CMS for more robust care continuity and transition standards, here.
Assessments/Transitions to Home and Community.The Council also supports these positions of the Coalition, as they further the Council’s primary objective to encourage re-balancing of long-term services and supports.
Rates.The Council generally supports greater transparency and clarity with regard to the dual demonstrations rate setting calculations. For example, the Council found that California does not provide adequate assurances that quality and access are not sacrificed as a result of achieving savings, and advised California to provide such assurances in order to protect this vulnerable patient population. Click here for details. With that said, the Council believes that overall, the duals demonstrations’ savings calculations appear arbitrary and lacking in transparency.
Click here for the Council’s general recommendations.
While the duals demonstrations will transform the way that dual eligibles receive care, many unknowns remain for providers, and home care providers specifically. The MOU does not cover how providers will be compensated. The MOU also does not mention if there are any quality standards to which home care providers will be held as part of the demonstrations.
Notwithstanding persistent stakeholder concerns (see here, here, and here) regarding these demonstrations, home care providers can look to them as opportunities to increase clinical coordination among the dual eligible population. In addition, these demonstrations will give home care providers rebalancing opportunities, as a stronger emphasis is placed on community based systems over institutional settings.
Home care providers are encouraged to keep abreast of demonstration developments on CMS’ website, and to contact the Council with any questions or concerns.