Coming in 2014 - Managed Care Expansion for all Medicare and Medicaid Services Received by Dual Eligibles in NYS

New York State is one of 15 states to receive a federal grant to develop a demonstration program to coordinate care for dual eligibles (People receiving both Medicare and Medicaid).  Under the Affordable Care Act, the federal government has funded states to develop these demonstrations with the hope of reducing costs -- if hospital re-admission rates can be reduced, for example, Medicare and Medicaid costs will be reduced.   A new federal office has been created to review and approve state plans -The Federal Coordinated Health Care Office (FCHCO), which is housed in the CMS Center for Medicare & Medicaid Innovation (CMMI). The webpage of this office includes all state proposals, statistical research and other information.  

NYS Proposal.   On  May 25, 2012, NYS submitted its final proposal to CMS -- posted at FINAL Demonstration Proposal to Integrate Care for Dual Eligible Individuals.    Click here for COMMENTS filed by a coalition of consumer organizations on JUNE 30th.  This amended the version posted for comments to DOH on May 3, 2012, for a Fully Integrated Dual Eligible (FIDA) plan at http://www.health.ny.gov/facilities/long_term_care/docs/second_demo_integrate_care_for_dual_elig.pdf, which amended the original proposal that was posted on March 22nd.     

The final proposal filed with CMS will create Fully-Integrated Dual Advantage (FIDA) managed care plans, but scales back the enrollment from the initial draft proposal.  The  FIDA plans would be charged with providing Medicare, Medicaid and long term care services to their members and hold the promise of coordinating the members’ health care. The enrollment would take place over the course of two years, starting in January 2014 and would enroll certain dual eligible New Yorkers living in eight counties -- all of New York City, both counties on Long Island, and Westchester County.   There would be two subgroups of initial enrollment.  First, all those who are then in Managed Long Term Care plans in these counties -  would be passively enrolled in FIDA managed care plans..   Second, other dual eligibles who do not receive community-based long term are services would be assigned to "health homes" if they have one or more chronic conditions such as AIDS.   Individuals would no longer have a regular Medicare or Medicaid card to see any physician of their choice -- they would now be limited to the provider network of their FIDA plan.  While many Medicare beneficiaries in New York State are already enrolled in Medicare Advantage plans, which limit the networks of all Medicare services, these FIDA plans would extend that coverage to all Medicare and Medicaid coverage.

• How does this compare to the roll-out of Managed Long Term Care in New York State?  I

In a separate initiative, the State is requiring all dual eligibles who rely on Medicaid long-term care services in the community, such as Medicaid personal care, to enroll in Managed Long Term Care plans.  These plans will take over the role that the local Medicaid programs (CASA's) did in the past -- assessing eligibility for home care services and determining the amount of services that are medically necessary.  These plans will also pay for and provide the services.  But -- these plans do not cover ALL medical services -- they don't cover primary care, acute care, emergency room, or inpatient care.   The individual continues to use their Medicare card or Medicare Advantage card for these services, supplemented by their Medicaid card.  The FIDA plans would be an expansion of Managed Long Term Care, so that the same plan would cover and control access to ALL Medicare and Medicaid services.

• For more info on Managed Long Term Care see this article Mandatory Managed Long Term Care Delayed until July 1, 2012  and this article Managed Long Term Care. 

Advocacy Concerns.   Consumer advocates submitted comments to the two draft State proposals.  Organizations that contributed to these comments include the Medicare Rights Center, the Center for Disability Rights, Center for Independence of the Disabled NY, Community Services Society of NY, Empire Justice Center, Legal Aid Society, New York Association on Independent Living, and Selfhelp Community Services, Inc.  The comments raise many concerns about the "passive enrollment" model, in which individuals will be automatically assigned to a plan with the right to opt-out.   Other concerns are voiced about adequacy of the plan's networks of providers -- will people with chronic health conditions have access to specialists they need?  Also discussed are oversight and accountability, grievance and hearing rights, contracting requirements and payment models to incentivize adequate care,  compliance with the Americans with Disabilities Act. 

• Jan. 9, 2013 - Performance Standards and Quality Measures for FIDA Program  --
• May 17, 2012 comments posted here.
• April 20, 2012 comments are posted here.

What happens Next?   The federal government will negotiate the final proposal with DOH.  

National Policy, Perspective and Experience of Other States.   The National Senior Citizens Law Center has created a website with resources for advocates on the Dual-Eligible proposals -- http://dualsdemoadvocacy.org/.    This website has information on proposals in all fifteen states, federal guidance about the dual eligible demonstrations, plus research and news items in this rapidly moving health policy arena. 

This article was authored by the Evelyn Frank Legal Resources Program of Selfhelp Community Services, Inc.