During a state Department of Health (DOH) Managed Care Policy and Planning meeting this week, DOH provided key updates on changes it is implementing in the Fully Integrated Duals Advantage (FIDA) Program which home care provider contractors and plans should take note of. The changes are as follows:
- Passive enrollment is suspended until further notice, except in limited circumstances (such as plan drops out of FIDA).
- DOH will be monitoring the effect of these changes prior to expanding enrollment into region 2 (Suffolk and Westchester) and does not expect it to start until after mid-2016.
- The coverage continuity period for out-of-network providers remains 90 days or until a Person Centered Service Plan (PCSP) is developed and implemented, whichever is later.
- Plans may use the existing MLTC schedule for completion of a participant’s Uniform Assessment (UAS) if the Participant is transferring from a sister MLTC/PACE/MAP plan; i.e., each FIDA enrollee transferring from a sister plan need not complete a new assessment until six months from the date of their last MLTC assessment.
- The FIDA plan must contact the participant and review any available medical record and claims history from the pre-enrollment period to determine changes in health status, health event, or needs that would trigger an updated UAS.
- If an updated UAS is required, it will be conducted within six months of the last UAS, and development of PCSP implemented within 90 days following the enrollment effective date.
- All other participants have a PCSP deadline of 90 days from the enrollment effective date.
Assurance and Participant Satisfaction
DOH/CMS and the Contract Management Team (CMT) will evaluate the FIDA Plan’s IDT delivery and operations. Specifically, the CMT will assess a Plan’s IDT performance against the following existing measures:
- In the last six months, did anyone from the participant’s health plan, doctor’s office, or clinic help coordinate care among these doctors or other health providers?
- How satisfied is the participant with the help in coordinating care in the last year?
- What is the percentage of participants discharged from a hospital who were readmitted within 30 days, either for the same condition as their recent hospital stay or for a different reason?
- What is the percentage of patients 65 years or older discharged from any inpatient facility and seen within 60 days following discharge by the physician providing on-going care, who had a reconciliation of the discharge medications with the current medication list in the medical record documented?
- What is the total percentage of all participants who saw their primary care doctor during the year?
- What is the percentage of participants in FIDA who reside in a nursing facility (NF), wish to return to the community, and were referred to preadmission screening teams or the Money Follows the Person Program?
- What is the number of nursing home-certifiable participants who lived outside the NF during the current measurement year as a proportion to those during the previous year?
- Follow-up required after hospitalization for mental illness.
- CMS has committed to an upward adjustment related to the Medicare Part A and B rates for all of 2016 and 2017.
- The 2016 rates are not yet final but will be retroactive to January 1, 2016.
- CMS will send rate letters to plans explaining the adjustment.
- CMS is conducting additional analysis of the Part D bids.
- CMS is open to reconsidering the assumptions used in determining the adjustment for calendar year 2016 based on revised projections of enrollment and recent experience in the demonstration.
- The quality withhold (QW) is effective upon execution of the Three-way Contract Amendments.
- The 2015 and 2016 quality withhold (QW) payments will be tied to participation through December 31, 2016. This will essentially add a new criterion to the QW calculation that excludes an organization from receiving QW amounts if the organization does not participate at least through 2016. (QW amounts are 1 percent of rate in 2015 and 2 percent in 2016).
- For any plans that do not continue through December 31, 2016, quality withhold amounts from 2015 and 2016 will be pooled and added to amounts earned by FIDA plans participating on January 1, 2017 (based on 2016 performance).
- The participant has a right to choose the make-up of its Interdisciplinary Team (IDT) and its members. The IDT can consist of just a care manager and participant, or broader, with a variety of members (from the original IDT list).
- IDT members may meet at different times. The care manager may separately meet with different IDT members in developing the PCSP.
- Provider participation in an IDT is adjustable, depending on member availability, items being discussed in a given meeting, or the needs, wishes, and goals of the participant.
- Primary care providers may sign off on a completed PCSP without attending IDT meetings.
- Plans have authorization over any medically necessary services included in the PCSP that are outside of the scope of practice of IDT members.
- IDT training will be encouraged, but not
- Plans develop their own procedures for communication among IDT members.
- Plans retain responsibility for effective and efficient information sharing among providers (including non-IDT participants), including any PCSP revisions.
- DOH/CMS and the Contract Management Team (CMT) will evaluate the FIDA plan’s IDT delivery and operations.
- FIDA plans must meet Medicare-Medicaid Plan Model of Care (MOC) elements and consistently update MOCs to reflect changes to the IDT policy.
- The CMT will assess a Plan’s IDT performance against specific data collected and percentages calculated.
- Completion of the bi-weekly and monthly dashboards is no longer required.
- DOH/CMS will streamline several reporting measures (e.g., NY1.1, NY1.2, and NY2.1) based on the new IDT policy (to be released). Changes to these measures would be applicable beginning with the 4th quarter of 2015 (October – December) reporting period.
Plans now have authorization to do the following:
- Market multiple lines of business under the Medicare Marketing Guidelines.
- Provide a written or verbal comparison (either DOH/CMS prepared or plan-prepared) among their MLTC (Partial, PACE, MAP) and FIDA programs.
- Conduct outbound FIDA marketing calls to individuals enrolled in any other Medicaid or Medicare product line with the plan or company.
- Organize in-person appointments if they are solicited by the individual.
- Conduct promotional activities and make nominal gifts at the Medicare Marketing Guidelines levels ($15).
- Send, with a prior approval from DOH/CMS, FIDA educational materials (e.g., letters, newsletters, etc.) to participants who have opted out.
- Plans may submit enrollment requests to Maximus (consistent with MLTC procedure). Maximus will process the enrollment and send letters, which include Independent Consumer Advocacy Network Independent Consumer Advocacy Network Independent Consumer Advocacy Network Independent Consumer Advocacy Network (ICAN) contact information, to the individuals that: 1) confirms the Participant’s enrollment in FIDA; 2) informs the Participant that choice counseling is available through Maximus; and 3) informs the participant of the option to switch or disenroll from a FIDA Plan at any time.
- Plans may remain on the phone when prospective participants call Maximus.
- Plans do not have to include both the plan phone number and enrollment broker number in their marketing materials.
ADA Attestation Form
- No provider should be terminated from a FIDA plan network for not answering in the affirmative to elements on the form.
- The form is to help FIDA participants identify which providers offer specified accessibility features.
- Completion or non-completion of the form, or responding in the affirmative to elements included therein does not alter existing obligations to comply with the Americans with Disabilities Act (ADA).
- FIDA plans must maintain a complete and accurate provider directory, including information collected by the form. FIDA plans have discretion on how to address provider refusals to complete the form.
- DOH will release the full set of FIDA Reforms, including an updated IDT policy.
- Reforms are effective immediately unless otherwise stated.
- Plans should make sure that they participate in the Friday FIDA plan conference calls.