2019 Elder Law Forum
June 5, 2019 Thank You to our Gold Sponsors: Housekeeping
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Neil Breslin Dan Bazile John McDonald III New York State Senator Spectrum News New York State Assemblymember MLTC Update: 2019-20 NYS Budget Changes and More Valerie Bogart, NYLAG May 2019 [email protected] 212-613-7310 Topics 1. MLTC plans closing – Why? a. Are Rates Sustainable? Proposal to Carve out Nursing Home Care, High Need Rate Cell b. What are members’ rights when plans close? New appeal rules - “Exhaustion” 2. CDPAP changes Budget 2019-20 3. FIDA program ending - new default enrollment to Medicaid Advantage/ Medicaid Advantage Plus 4. MLTC Lock-In Rules & LHCSA CAP MLTC PLANS CLOSING! 8 MLTC plans have closed – 17,000 members affected
1. GUILDNET – closed in Westchester, Long Island in 2016, then its 3 plans closed in NYC January 2019; NYC Members were auto- assigned to another plan Jan. 2019 if they didn’t pick a plan after earlier notice. • Guildnet Medicaid Advantage Plus - 478 members • Guildnet Gold Plus (FIDA) 418 members • Guildnet MLTC 7,332 members TOTAL 8,228 members 2. UNITEDHEALTH MLTC – closed in 6 UPSTATE counties Feb. 2019. Remains open in NYC. See next slide – about 2300 affected 3. ICS closed April 1, 2019 – NYC only. 6,100 members Upstate UnitedHealth closed 2/19
UnitedHealth Enrollment County 12/2018 ALBANY 90 BROOME 221 ERIE 155 MONROE 451 ONEIDA 85 ONONDAGA 261 Total in plan closing upstate 2,263 Plan Consolidation - NYC • After Guildnet & ICS closed, there are now 18 MLTC plans in NYC -- down from 25. Top 9 plans by enrollment below. April-19 April-19 MLTC plan NYC only Outside NYC 1. Centers Plan for Healthy Living 29,400 4,028 2. INTEGRA (Personal Touch) 15,769 2,116 3. VNS CHOICE 15,115 3,258 4. Senior Whole Health 14,473 246 5. Senior Health Partners (HealthFirst) 14,247 847 6. ELDERSERVE 13,364 1,210 7. ELDERPLAN (HomeFirst) 11,762 2,280 8. VillageCareMAX 11,269 0 9. Fidelis 8,451 15,016
Smallest 5 NYC plans have < 5,000 members each Smallest is Montefiore with 1,312 enrollees. Complete list in materials Plan consolidation – 2019 Upstate • Of the 56,397 upstate/Long Island MLTC members in April 2019, 2/3 are in these SIX MLTC plans:
No. of Counties Non-NYC PLAN NAME outside NYC Apr-19 1. FIDELIS CARE 56 15,016 2. VNA HOMECARE OPTIONS 48 7,525 3. CENTERS PLAN FOR HEALTHY LIVING 6 4,028 4. AGEWELL NEW YORK 3 3,674 5. ICIRCLE CARE 21 3,546 6. VNS CHOICE 27 3,258 Subtotal 6 largest plans 66% 37,047 Of 14 other plans, 6 each have > 1000 members: Hamaspik Choice, Elderplan, Integra, Aetna, Wellcare, Kalos Health, Archcare, & Elderserve. 6 other plans < 1000 members. 34% 19,350 See complete list in materials. Why have MLTC plans closed? • Both Guildnet and Independence Care Systems publicly stated that the monthly “capitation” rate or premium paid by the State was inadequate for the plan to pay for the highest need members, including: • Nursing home residents (since 2015, MLTC plans are responsible for keeping members who enter NHs; plan pays the NH. Status of this discussed below) • 12-24 hour/day personal care and private duty nursing care • Both Guildnet and ICS provided more high-hour home care than some other plans. ICS’ mission was to serve people with physical disabilities, including people with quadriplegia, MS, etc. who more commonly need 12+ hours/day of home care. Guildnet’s mission for visually impaired. Is Rate Methodology Structured to Keep Plans Open and Serve High-Need Members?
• The rate structure must take into account the high cost of the highest need consumers. There is disagreement over how to accomplish this goal. • RISK ADJUSTED RATES – The State calculates rates under a complicated methodology, that takes into account how many HIGH NEED consumers are in the plan. This is called Risk Adjustment. • In the managed care “capitation” model, the plan receives the same risk-adjusted monthly premium for each and every member – “Per Member Per Month” (PMPM). If all of these premiums are combined in a pot, the Plan theoretically has enough to pay for those with high needs. Consolidation could help – bigger pot – plan can spread high costs to all. A look at MLTC income vs. costs MLTC Capitation Rates (estimated average) $ 4000-5500/mo. Aide services (estimated average $18/hour – higher downstate with minimum wage, wage parity – see next slide re increases) • 5 days x 7 hours $2,730/mo. • 12 hours x 7 days $6,670/mo. • Live-in x 7 days @ 13 hours/day $7,117/mo. • Split – shift 2x12 $13,340/mo.
Average Medicaid Nursing Home (non-specialty – excl. AIDS, vent, pediatric) • NYC $8,604/mo. • Albany $5,811/mo. • Nassau $7,898/mo.
Plus admin, care management costs, and other services – adult day care, dental, supplies, transportation, audiology, nursing, etc. 14 15 Minimum wage/ wage parity 2018-19 Rate paid to LHCSA higher than wages in chart NYC- Large NYC – small Westchester, 1/2017 employerNYC- Large EmployerNYC – small Long Island Rest of State 11+employer https://www.health.ny.gov/health_care/medicaid/redesign/mrt61/ 2017-10-31_ww_parity_min_nyc.htm ; https://www.labor.ny.gov/workerprotection/laborstandards/workp rot/minwage.shtm Do Managed Care Rates Work? – Consumer View • ICS and consumer advocates say “risk adjustment” alone is not enough. The highest cost care is so expensive that paying plans the same rate across the board can’t work. • Unlike most insurance, EVERY MEMBER needs SOME CARE. Plan can’t save that much on low-need members. • Capitation gives an inherent incentive for plans to deny high hours when needed. • Plans use pretexts or delays to discourage high-need people from enrolling. • Plans delay processing -- or ignore -- requests to increase hours. Consumers don’t know their rights • Plans reduce hours of home care – though most can win appeals with help, some don’t know they can appeal or how. State Proposal that will Impact Rates -- Nursing Home “Carve-Out” • One State proposal APPROVED in NYS Budget 2018-19 and pending before CMS is to take Nursing Home Care out of the MLTC package, once a member is permanently placed for 3 months. • This is a reversal of state policy since 2015 when Nursing Home care was “carved in” to the MLTC and mainstream managed care package. Since then: • MLTC members who enter a nursing home stay in the MLTC plan – even if stay is permanent. • Nursing home residents who were NOT in MLTC plans before admission now must enroll in MLTC once Institutional Medicaid is approved (5-year-lookback). • 28,000 MLTC members in NH (per DOH May 2018) – about 10% of all members State Proposal that will Impact Rates -- Nursing Home “Carve-Out” • Now, if approved by CMS, after a member is permanently placed in NY for 3 months, would be disenrolled from MLTC plan, and NH would be paid directly by Medicaid Fee for Service. NH residents approved for Institutional Medicaid would no longer be required to enroll in MLTC. • Supposed to save $122 million/ year. State said savings from eliminating duplicate care management. • But real savings because cheaper for State to pay NH Fee for Service for 28,000 people than increase the PMPM capitation rates for 225,000 people to include high cost NH care, as State did in 2015. • Consumers have big concerns – see next slide. Consumer Concerns about “Carving out” Permanent Nursing Home Care from MLTC • If plan not on the hook for cost of NH care, plan has incentive to deny increases in home care to members in community, and say appropriate plan of care is NH. • If member temporarily in rehab → MLTC refuses to reinstate or increase home care when ready for discharge. After 3 months, would be disenrolled. • It will be harder to leave a NH if not already in MLTC plan. • No MLTC plan wants to enroll someone who needs high-hour care. No appeal rights if not in plan! • Consumers want a high need “rate cell” to pay plans more for members who need 12-24/hour home care to give plans incentive to keep out of NH. Otherwise plans will never approve 24-hour care. (Split shift costs $14,000+/mo) or LPN. 19 Rate methodologies must encourage plans to give necessary home care • In MLTC, paying plans the “average” cost of care for its membership does not work. Some members need such high –cost care that the plan cannot or will not pay them. • EXAMPLE: ALS, MS ► need Private Duty Nurses for skilled care. Dementia, stroke, quadriplegia ► need 24-hour personal care. • Costs high -- plan cannot or does not want to pay it from its capitation. • These high-cost services should be taken out of the MLTC package and paid FFS, the same way State asking CMS to take nursing home care out of MLTC and make it FFS. • Insurance mechanisms like “stop-loss” can be used to protect plans from the extremely high cost of this care. • Now the plan has no incentive to approve this care, leading to denials and lengthy appeals and putting vulnerable consumers at risk. • Since high cost NH care being taken off plan’s plate, same should be done for high cost community care. Otherwise serious ADA concerns forcing institutionalization. Changes needed to prevent “cherry picking” – Auto- Assignment Bill • After consumer approved for MLTC by NY Medicaid Choice after a Conflict Free assessment (CFEEC), Consumers face roadblocks enrolling in a plan if need HIGH HOURS. • Plans use pretexts to delay or discourage enrollment. • Plan tells consumer who needs 24/7 will get 6 hours/day. Consumer cannot appeal because not yet a plan member. • Consumer shops around (if other plans available), then CFEEC expires after 75 days.. More delays. • BILL A A7578 (Gottfried) / S5485(Rivera) would auto-assign member to a plan if they cannot manage to enroll before CFEEC expires. • Aligns MLTC with mainstream managed care, where members auto-assigned after 30 days. • Once in plan, member can appeal amount of hours. • Plans can’t avoid enrolling anyone. (copy in materials with NYLAG Memo of Support) • Especially needed if nursing home care carve-out approved by CMS. PLAN CLOSINGS – CONSUMER RIGHTS DOH Transition Policy 17.02 23 Consumer protections when plan closes - background • Early MLTC closings 2015-17 – consumer on her own to enroll in a new plan. If prospective plans refused or delayed in coming to assess, or consumer lacked wherewithal to find a new plan, she’d be disenrolled from closed MLTC with no replacement. Services stopped. • New plan could give FEWER HOURS than closing MLTC gave. • 9/2015 HomeFirst (ElderPlan) ceased taking new members in 7 upstate counties • June 2017- Guildnet closed Long Island, Westchester - 4000+ members • It was better if the closing plan merged with another plan or arranged to transfer its members to a new plan – so consumers had continuity. • Jan 2016 - EmblemHealth MLTC closed - –1300 members → Guildnet unless picked another plan. (NYC, Long Island, Westchester) • 2/2017 – Centerlight MLTC closed, 5000 members → Centers Plan • 9/2017 – AlphaCare merged into Senior Whole Health – 4460 members • Jan 2018 – North Shore LIJ closed, 5600 members → Centers Plan for Healthy Living (about ½ of the members in NYC) 24 Plans closing or reducing service area TRANSITION RIGHTS MLTC Policy 17.02 • 9/2017 – DOH ISSUES MLTC POLICY 17.02 Plan Transition Process – MLTC Market Alteration." (copy in materials) • Transition policy goal to ensure continuity of services for members when their MLTC plan closes. (described on next slide) • Result of advocacy by: • Consumer advocates when HomeFirst pulled out of upstate counties and Guildnet in Long Island and Westchester. • NYLAG brought a lawsuit in 2017 when Guildnet announced closing in Long Island & Westchester – claiming lack of transition rights violates due process. All MLTC policies cited here available at https://www.health.ny.gov/health_care/medicaid/redesign/mrt90/mltc_policies.htm (copy in appendix) 25 Plan Closings – Transition Rights MLTC Policy 17.02 1. NOTICE - NYMC will send notice to members of closing plan 60 days before closing, to select a new plan in 60 days. 2. AUTO-ENROLLMENT – no PLAN ASSESSMENT NEEDED • Member may call NYMC to do “warm transfer” – enroll directly into new plan without a plan assessment. • If they do not pick a plan, they will be auto–assigned to a new MLTC plan (not to MAP, PACE, or FIDA). 3. TRANSITION RIGHTS - New plan must continue existing plan of care with same providers "for the earlier of: • 120 days after enrollment; or • until the new plan has conducted an assessment and the enrollee has agreed to the new plan of care. This applies whether client picks plan or is auto-assigned SPECIAL ICS 1-Year Transition Rights • Independence Care Systems closed April 1, 2019. • 5800 members affected. Only in NYC. • Members received notice that could select a plan of their choice, but if they did nothing, they would be assigned to VNS CHOICE April 1, 2019. • VNS CHOICE must continue same plan of care for ONE YEAR from enrollment, which is April 2019 or March 2019 if consumer switched earlier. • If member chose a different plan, that plan must only give the 120 days of Transition Rights in Policy 17.02. • Member may still transfer from the other MLTC plan to VNS CHOICE after April 1, 2019 and get one-year transition rights from VNS Choice, with the year ending April 1, 2019. 27 MLTC Plan Closings –Concerns re 17.02 1. New plan may reduce hours before 120 days after enrollment if enrollee “agrees.” Does not require notice to member confirming “agreement” – with appeal rights. Members may feel pressured to “agree.” (Advocates think this violates due process and regulations). 2. What happens After 120 Days? MLTC Policy 17.02 - Does not address whether plan can reduce services at end of 120 day transition period. But -- MLTC Policy 16.06* allows plans to reduce service only if they send notice of reduction specifying why a permitted reason applies. More below. *https://www.health.ny.gov/health_care/medicaid/redesign/mrt90/mltc_policies.htm WHEN CAN PLAN REDUCE HOURS? WHAT ARE APPEAL RIGHTS – NEW “EXHAUSTION” RULES • After an MLTC plan closes and the new plan tries to reduce hours • Any time an MLTC plan reduces hours • Any time an MLTC plan denies a request for new services or more hours After MLTC Plan Closes – or at any other time -- Plan May Reduce Services only for Cause – State Regulation and MLTC Policy 16.06 MLTC plan may reduce services only if it sends written notice that describes one of these changes: 1. medical or mental condition has improved such that no longer require the same services, or 2. social circumstances have changed so you no longer require the same services (family member now more available and willing to help), or 3. mistake occurred in the previous authorization, which, if corrected, results in fewer hours. 16.06 says not a “mistake” if new assessment says you need fewer hours than were determined from an earlier assessment. There must be a particular mistake. • Example -- earlier assessment allowed x hours for aide to do laundry because it was thought there were no washers in the building. When it turned out that the building had a laundry room, fewer hours were needed. 18 NYCRR 505.14(b)(5)(c), MLTC Policy 16.06. See also DOH MLTC Policy 16.07 - needs must be assessed on an individual basis, not using standard “task times.” Posted at https://www.health.ny.gov/health_care/medicaid/redesign/mrt90/mltc_policies.htm WARNING: Rules for MLTC Reductions of Hours May Change! • In the 2019-20 NYS Budget, DOH said it will propose changes in State regulations to give plans more “flexibility” to identify reasons to reduce or deny hours of personal care, which would also revise Policy 16.06. • Policy 16.06 is based on state regulations that limit reductions except for cause– adopted in 1996 after a Federal court decision in Mayer v. Wing -- class action challenging arbitrary cuts by NYC HRA in home attendant/personal care hours. • Advocates say DOH cannot change those rules. Court decision found that once determined to need x hours of home care, arbitrary reductions without cause violate Due Process clause in Constitution. • NYS Budget savings projected $50 million this year and $50 million next year, presumably thru MLTC rate cuts. NEW Rights to Appeal a Reduction - After Transition Period Ends - or any other time • Since May 2018, MLTC members must first request an Internal Plan Appeal if the MLTC plan denies or reduces services. They may not request a Fair Hearing until this appeal is decided. • This was required by a change in federal regulations. See materials online about the new appeal system. http://www.wnylc.com/health/entry/184/ 1. Plan must first send an Initial Adverse Determination (IAD). Member must file an internal Plan Appeal, not a fair hearing. 2. If he plan denies appeal, issues a “Final Adverse Determination” (FAD) notice. Member may request Fair Hearing, • If the plan is reducing services, BOTH notices must be mailed 10 days before the reduction takes effect. Member has 10 days to request a Plan Appeal, and then a Fair Hearing to get AID CONTINUING. • Watch for former Guildnet, ICS & UnitedHealth MLTC members receiving reduction notices from their new plans! NEW Appeals Process and Vocabulary 32 Red equals change from previous deadlines • Plan “INITIAL Adverse Determination” notice (IAD) • Deadline (if member requested new or increased service): 1 14 calendar days/ 72 hours fast track* • Member Requests Plan Appeal 2 • Deadline: 10 days for Aid Continuing; 60 days other • Plan “FINAL Adverse Determination” notice (FAD) 3 • Deadline: 30 calendar days (was 45)/ 72 hours Fast Track* • Member Requests Fair Hearing • Deadline: 10 days for Aid Continuing; 120 days (was 60) other • Optional: External Appeal request if medical necessity but no Aid 4 Continuing * Plan may extend 14 days if need more info & in member’s interest 33 Warning: Plan must give “Notice to Reduce or Stop Services” After MLTC Plan A closes, and member transfers to Plan B, Plan B must continue same hours for 120 days. During that time, Plan B will do a new UAS assessment. If plan says that assessment says member should receive fewer hours than Plan A authorized, this is a REDUCTION. Sample Notice next page ➢New plan may incorrectly say this is an “Initial Authorization” and not characterize the change as a REDUCTION because it’s this plan’s first assessment. But it is a reduction and member entitled to advance Notice (Initial Adverse Determination) and opportunity to request Aid Continuing. ➢If plan sends wrong notice, or no notice- request a Plan Appeal with Aid Continuing. ➢If plan doesn’t give Aid Continuing -- contact ICAN (last slides) and request a Fair Hearing. ➢New assessment is NOT enough of a reason to reduce services. Must be one of the listed grounds in MLTC Policy 16.06. Initial Adverse Determination Notice Look for 3 KEY DATES in Reduction Notice* 1. Notice Date • This is the date the plan printed the notice and, hopefully, mailed it to the member 2. Effective Date1 • If the Notice Date or Postmark Date are fewer than 10 calendar days before the Effective Date, this is a Defective Notice. • Get Postmarked envelope! 3. Appeal deadline (60 days) 42 CFR § §438.404(c)(1) & 431.211; 18 NYCRR §358-2.2(a) *https://www.health.ny.gov/health_care/managed_care/plans/appeals/docs/2017-11-20_initial_reduce_services.pdf. 34 Confusion from new MLTC Appeal Rules • The new rule to “exhaust” plan appeals has now been in effect one year. • Unfortunately, habits are hard to change. If you mistakenly request a Fair Hearing first, without first requesting a Plan Appeal and waiting for the decision, the Fair Hearing will still be scheduled. However, at the hearing, the ALJ may tell you to withdraw the fair hearing request. Or you will lose the decision because you didn’t “exhaust” the plan appeal. • By that time it may be too late to request a plan appeal – time limit is 60 days after the Initial Adverse Determination (IAD) notice. 36 What if Member Requests Fair Hearing instead of Plan Appeal? Plan role • DOH told plans that when they are notified by OTDA that a Fair Hearing was requested, if no Plan Appeal was requested, • “…The plan may contact the enrollee, remind them of the need to ask for a Plan Appeal, and ask if they wish to file a Plan Appeal. The plan may contact the enrollee and attempt to resolve their dispute prior to the fair hearing. UNDER NO CIRCUMSTANCES MAY A PLAN INTERFERE WITH THE FAIR HEARING PROCESS OR SUGGEST/DIRECT AN ENROLLEE TO WITHDRAW THEIR FAIR HEARING REQUEST.” (Slide 19)* • If the matter is “resolved” less than fully favorably with the plan, plan must still send notice with appeal rights. https://www.health.ny.gov/health_care/managed_care/plans/appeals/docs/2018-04-13_appeals.pdf 37 Must Member pay for “Aid Continuing” if lose appeal? • Plan notices must “describe the circumstances, consistent with State policy, under which the enrollee may be required to pay the costs of … services” provided if request Aid Continuing. 42 CFR 438.404(b)(6). • State DOH FAQ* says plans may recoup cost of services during Aid Continuing period, but only: • after FAD is issued and member fails to request a hearing within the 10-day Aid Continuing period. NYLAG says should be no recoupment until after 120- day time limit to request FH. • NOTE: Most Fair Hearings on reductions of services are in FAVOR OF THE MEMBER (> 90%). See Medicaid Matters NY report.** The potential liability should not deter member from appealing. *See DOH l FAQ # VII. 3, 1. 2/7/18 https://www.health.ny.gov/health_care/managed_care/plans/appeals/ 2018-02-07_2016_final_rule_faqs-jan.htm ** http://medicaidmattersny.org/managed-care/ 38 Plan must provide case file to enrollee and rep even without request • Plan must provide the enrollee and his or her representative the enrollee's case file, including medical records, other documents, and any new or additional evidence considered, relied upon, or generated by the plan in connection with the appeal. This information must be provided free of charge. 42 CFR 438.406(b)(5). • See DOH FAQs on producing file - https://www.health.ny.gov/health_care/managed_care/plans/appeals/2018-02- 07_2016_final_rule_faqs-jan.htm (V. #2-4) • Unless other requested, plan must send by regular mail • Differentiates “evidence packet” provided for fair hearing • Must be provided “sufficiently in advance of resolution timeframe.” • Plan must provide file even if not requested. • Unclear if HIPPA required for plan to send file directly to the representative - OCA Form No. 960 - Authorization for Release of Health Information Pursuant to HIPAA . 39 Right to present new evidence • Plan must consider new evidence submitted in appeal. 42 CFR 438.406(b)(2)(iii) • Must provide enrollee a reasonable opportunity, in person and in writing, to present evidence and testimony and make legal and factual arguments. The plan must inform the enrollee of the limited time available for this sufficiently in advance of the resolution time frame for appeals. 438.406(b)(4) • TIP: On the Appeal Request Form that plans must attach to their IAD notice, there is a checkbox if you want to include additional documents with the appeal request, or if you want to give information in person. You could also write in that you would like time to submit additional documentation. 2019 NYS BUDGET • Consumer-Directed Personal Assistance Program State Efforts to Halt MLTC Growth • In the last few years, the State has been alarmed about the growth in MLTC enrollment. Currently 230,000. Next slide shows 12% growth just in past year. Doubled since 2014. ▼ enrollment = ▼ State costs $$ • State reducing enrollment in a few ways: • Carving out permanent nursing home residents – ▼about 10% enrollment • Capping number of LHCSAs in MLTC plans – LHCSAs market to and bring in new enrollees • Restricting marketing by CDPAP’s and MLTC plans – 2017 budget ban on marketing for CDPAP challenged in court by CDPAP plans • 2018-19 – New restrictions on CDPAP CDPAP Backgrounder • Consumer-directed alternative to medical model started in 1970’s with advocacy by disability community • 1992 –Amended state Nurse Practice Act in state Education Law to allow CDPAP personal assistants to perform routine but complex skilled nursing tasks, similar to family members. • Agencies called “Fiscal Intermediaries (FI)” because don’t employ personal assistants, only administer payroll and benefits. Consumer is the employer – hires, fires, trains, schedules. • 2015- state law expanded - Family members may be personal assistants – adult children for elderly parents, parents for adult children with disabilities • With aide shortage, especially upstate, CDPAP enables MLTC plans to meet demand and staff cases ↑ CDPAP State Budget -CDPAP Changes • State sees CDPAP growth as contributing to MLTC growth • 2017 - required FI’s to apply to be licensed – but dropped • 2018 - banned marketing by FI’s – lawsuit suspended ban • 2019 budget: • will reduce number of FI’s thru consolidation – Workgroup convened to address alleged overutilization, selection of FIs assuring geographic and cultural availability & experience service people with disabilities, best practices, quality measures • Reduce reimbursement rates for CDPAP by shifting to “per member per month” methodology instead of incorporating admin. costs in hourly rate. FI’s warn that many – even ALL – won’t survive the significant cut. • Enacts transition protections for consumers in FIs that close – bans “non- compete” clauses for employees; notice to consumers LOCK-IN FOR MLTC Awaiting approval by CMS MLTC Lock-In • LOCK-IN – State law amended in budget 2018-19 but not yet approved by CMS. If approved, after a certain date, anyone who joins an MLTC plan for the 1st time, or switches plans after that date: • May change plans ONCE within 1st 90 days; • After that, they are locked into that plan for the next 9 months (the rest of the 12-month year) unless they have good cause. • Good cause may include (from proposed DOH notice to members): • the enrollee is moving from the plan's service area, • the plan fails to furnish services, or • it is determined the enrollment was non-consensual • to continue being cared for by home care worker 46 MLTC Lock-In con’d/ • After the 12 months, individual may change plans any time, but then after a 3-month grace period in new plan – again locked in for 9 months. • WARNING: In a “voluntary” transfer, either after 12 months or if “good cause,” there are no transition rights! New plan not required to give same hours! Don’t transfer without written plan of care that is adequate! • Does not apply to Medicaid Advantage Plus, FIDA, or PACE. Only regular MLTC. • PROCEDURE NOT CLEAR to request good cause https://www.health.ny.gov/health_care/medicaid/program/u pdate/2018/2018-06.htm#mltc 47 48 MLTC Lock-In – not Two-Way! Though MEMBER locked in to a plan for 9 months, Plans retain the ability to involuntarily disenroll a member for the reasons specified in their contract, which includes: 1. failure to pay spend-down, 2. hospitalized for greater than 45 days, or 3. the enrollee was absent from the service area for more than 30 consecutive days. 4. NEW DOH POLICY? – requires plan to disenroll a member who hasn’t received services in plan of care for one calendar month if member didn’t notify the plan. May harm those “difficult to serve” with LHCSAs and aides turning over. 49 Cap on Number of LHCSAS: What is a LHCSA? • MLTC plans have subcontracts with Licensed Home Care Services Agencies (LHCSA) to provide personal care services – the main service provided by MLTC. • A LHCSA is not usually a Medicaid provider in its own right, so may generally not bill Medicaid directly. Instead it bills the MLTC plan or CHHA with which it contracts, which pays the LHCSA. The MLTC or CHHA is paid by Medicaid. • There is one exception in which a LHCSA may bill Medicaid directly – when it contracts with a local DSS/HRA to provide personal care services “fee for service.” In NYC these are known as home attendant services. NY Pub. Health Law § 3605, 10 NYCRR § 763.5 50 CAP on number of LHCSAs per MLTC Plan 2018 state law PHL 4403-f(7)(j)(x) says: • Downstate – MLTC plan may contract with only: • one LHCSA per 75 members, eff. Oct. 2018, and • one LHCSA per 100 members as of Oct. 2019 (ICS said would have to cut from 150 to 65 agencies)* • Upstate – MLTC Plan may contract with only: • One LHCSA per 45 enrollees as of Oct. 2018 and • One LHCSA per 60 members as of Oct. 2019. • DOH may allow exceptions where needed for continuity of care. • Must still meet “network capacity” minimum 2 LHCSAs/county. 42 C.F.R. § 438.207. • If an MLTC plan is unable to provide covered services through its network, the plan must arrange with out–of–network providers. https://www.crainsnewyork.com/article/20180410/HEALTH_CARE/18 0419994/new-home-care-rules-could-hurt-small-agencies LHCSA CAP - DOH Guidance to plans Aug. 17, 2018: • MLTC plan must send written notice of termination to all enrollees receiving care from the terminated LHCSA within LATER OF 15 days of the notice of termination to the LHCSA, or by 9/1/18. • The notice must inform the enrollee of options to stay with current home care worker, which may include: • changing to a different LHCSA if aide is moving to a new LHCSA; • enrolling in a different MLTC plan if aide employed with a LHCSA that is contracted with another plan; or, if applicable, • requesting a three–month exception for continuity of care purposes (next slide) • The notice must include contact information for the New York Medicaid Choice (Phone: 1–888–401–6582) to switch plans to keep home care worker. https://www.health.ny.gov/health_care/medicaid/redesign/mrt90/mltc_policy/lhsca_contract_guidance.htm 51 52 LHCSA CAP – Exceptions to Cap 1. Continuity of Service up to THREE MONTHS If the enrollee wishes to be cared for by home care workers employed by the current LHCSA, MLTC plan may continue contracting with current LHCSA for 3 months – won’t count toward cap. • MLTC plans must notify DOH at [email protected] of 3-month extension. Plan does not need to request permission from DOH. 2. Plan may request exception from DOH to continue contract with a LHCSA above CAP if Needed to Ensure Adequate Access to Special Need Services in geographic hard to serve area, or to ensure cultural or linguistic competency. • Cultural and linguistic competency is the ability of organizations and practitioners to recognize an individual´s cultural beliefs, values, attitudes, traditions, language practices and health practices and apply this knowledge to influence positive health outcomes. • Plan must show impact on enrollee, that enrollee can’t switch to a different LHCSA • Does “special need” include psychiatric impairment – harm from disruption of relationship with trusted longtime aides? Should be reasonable accommodation of disability. LHCSA Cap and new Lock-In Rule • If and when CMS approves the proposed LOCK-IN rule, which bans members from changing plans after 3-month grace period, DOH said one of the exceptions will allow members to change plans to keep their aide. • This will allow members to change plans to keep their aide if plan drops LHCSA because of the LHCSA cap. • WARNING: If member changes plans to keep aide, this is considered by DOH to be voluntary, so new plan may authorize lower hours. Member has no Transition rights and no right to “aid continuing.” Member must request an increase in hours. FIDA CLOSING END OF 2019 New push to expand to Medicaid Advantage Plus Thanks to Medicare Rights Center for some of the content of these slides End of FIDA – end of 2019 • FIDA is a “Dual Eligibles Demonstration” that was solely in NYC, Long Island & Westchester. 5-years ends Dec. 31, 2019 – won’t be continued. • FIDA is similar to PACE and Medicaid Advantage Plus: • All 3 types of plans combine in ONE managed care plan: 1. Medicare Advantage Dual Eligible Special Needs Plan (Dual-SNP) including prescription drugs 2. MLTC plan 3. All other Medicaid services not covered by MLTC • “Fully capitated” plans – Plan paid to provide Medicare AND Medicaid services. • Member must receive all services in-network. All network providers accept Medicare and Medicaid. End of FIDA – end of 12/31/2019 • Members in the 6 FIDA plans will be auto-assigned to the same company’s Medicaid Advantage Plus (MAP) plan, unless they have chosen another option before then (after receiving notice of options). • FIDA plans may outreach to members to inform them about their MAP even now – but if they change early will they have transition rights? • Or may join PACE or MLTC. If switch to MLTC, consumer chooses Medicare model: 1. Medicare Advantage plan of their choice 2. Original Medicare + Part D drug plan • Transition rights- pending DOH decision on whether new plan must continue same services as FIDA for 120 days. (Policy 17.02 does not cover FIDA; ) See 2nd stakeholder session at https://www.health.ny.gov/health_care/medicaid/redesign/integ rated_care/ Dual-SNP expansion statewide • 2019 CMS changes allow “default enrollment” of people in Medicaid “mainstream” managed care (MMC) plans into DUAL-SNPs when they become eligible for Medicare. (Most were on MAGI Medicaid on NYS of Health and now will have Medicaid transferred to LDSS). • Not yet approved in NYS. • EXAMPLE: Ms. F is 64 years old and has an MMC plan from Fidelis. She turns 65 on May 17th and is eligible for Medicare effective May 1st. What should happen if Ms. F’s MMC plan Fidelis has an approved D-SNP using default enrollment? Default enrollment example • By March, Ms. F should have her Medicaid redetermined using age, blind, disabled budgeting, with Medicaid transferred from NYSofHealth to LDSS. • At the start of March, Ms. F should receive a notice from Fidelis explaining that she will automatically receive D-SNP coverage starting on May 1 unless she declines. The notice should explain how her D-SNP coverage will differ from her current MMC plan and explain how to choose alternative coverage. • Ms. F would be defaulted in: • Fidelis Medicaid Advantage if she is not receiving LTC from Fidelis MMC plan (Personal care, etc) • Fidelis Medicaid Advantage Plus if she is receiving LTC from Fidelis MMC plan Get Help From ICAN! Call 844-614-8800 TTY Relay Service 711 Email [email protected] Website: http://icannys.org 60 Coffee Break Please also use this time to visit our exhibitors: AARP New York Consumer Directed Choices Pierro, Connor & Strauss Albany County NY Connects Doyle Medical Monitoring Quontic Bank Atria Senior Living EverHome Care Advisors Right at Home Albany Albany Guardian Society Eddy SeniorCare The Center for Special Needs Ballston Spa National Bank Trust Administration Eddy Senior Living Visiting Nurse Service of New Lisa’s Care NYSARC Trust Services York Long Term Care Planning Project June 5, 2019 63 Context • In his 2017 State of the State address, Governor Cuomo directed State agencies to employ a more proactive and interactive approach to improve the health of New York’s overall population and become the healthiest state in the country. • Using the State’s Prevention Agenda as the overarching framework, the Governor launched a Health Across All Policies approach, where health and non-health related state agencies work together to take into account how policies and programs can positively impact public health. This approach is broad-based and inclusive of community partners, local government, and philanthropy and benefits New Yorkers of all ages in all geographic areas. Prevention Agenda: https://www.health.ny.gov/prevention/prevention_agenda/2013-2017/ Health Across All Policies: https://www.health.ny.gov/prevention/prevention_agenda/health_across_all_policies/ 64 The Goals of Health Across All Policies include: • Consideration of how policies, programs, and initiatives may support being the first age-friendly state in the nation. • Design and implement multi-agency projects supporting population health and healthy aging. • Incorporating public health metrics into the New York State Department of Health's Prevention Agenda. • Implement system-wide mechanisms for State agencies to embed Health Across all Policies, age-friendly, and healthy aging into all aspects of our government work. 65 • As a result of the Governor’s directive to include healthy aging in State agency policymaking, New York State was designated the first age-friendly state in the nation by the World Health Organization (WHO) and AARP in 2017. • New York ranked high in the eight age-friendly and livable community domains outlined by WHO and AARP, which include: • Outdoor spaces and buildings; • Transportation; • Housing; • Social participation; • Respect and social inclusion; • Work and civic engagement; • Communication and information; and • Community and health services. Age-friendly domains: https://www.aarp.org/livable-communities/network-age-friendly-communities/info-2016/8-domains-of-livability-introduction.html 66 • Building on the State’s age-friendly strategies, the Governor has continued to promulgate a series of policies preparing for the emerging needs of a growing aging population, including: • Issuing Executive Order #190, which directs all State agencies to consider the impact of their policies and procurements on health and healthy aging, aligned with the eight domains of an age-friendly community. • Setting a goal of making 50 percent of all health systems in the State age- friendly by 2023, including the establishment of age-friendly emergency rooms better equipped to provide care to aging New Yorkers with cognitive and other physical disabilities. 67 • The New York State Office for the Aging, in partnership with the Department of State, Department of Health, Health Foundation of Western and Central New York, and the New York Academy of Medicine, will fund 10 Centers of Excellence (COE) - one per Regional Economic Development Center (REDC) to: replicate the State’s Executive Order at the county level; sign on to be a certified age-friendly community as defined by AARP/WHO; or a combination of both. The partnership will include learning collaboratives for grantees and the creating of Age-Friendly Regional COEs to work with other communities interested in pursuing age-friendly policies and programs. • Launching a Long Term Care Planning Project to examine New York’s long term care system and analyze, evaluate, and identify existing service gaps, and prepare a strategic plan on meeting the emerging needs of New York’s aging population over the next decade. 68 Examples of Achievements Supporting the Governor’s Goals and Vision • Since signing the Complete Streets Act in 2011, 12 counties and more than 100 villages, towns, and cities have adopted Complete Streets policies to consider the safe, convenient access, and mobility of all roadway users of all ages and abilities. • More than 100,000 units of affordable housing will be created and preserved throughout the State by 2021. • As part of the Downtown Revitalization Initiative, New York State has awarded three rounds of $10 million to 10 downtown areas per round, prioritizing awards to municipalities that have age- friendly policies in place. • As part of Governor Cuomo's $10 billion House NY 2020 commitment, 8,659 affordable housing units have already been created for older adults by New York State Homes and Community Renewal since 2011—1,270 of which are part of the House NY 2020 plan. The plan aims to establish and preserve over 100,000 units of affordable housing throughout the State by the end of 2020. 69 • Ten regional Sustainable Development and Collaborative Governance conferences were held in 2017 to discuss the benefits of sustainable community planning and certification as an age- friendly community. The events helped promote collaboration by bringing together community development experts, local elected officials, and business leaders. The culmination of these conferences was the release of a handbook for local governments and nonprofits that serves as a one-stop resource for State-funded grants and programs. • In 2017, the New York State Office for the Aging created the nation’s first statewide mobile app to connect more than 3.7 million older adults with easily accessible material about benefits, programs, and services, including information regarding health and wellness, housing, and transportation options. • The National Network of Public Health Institutes (NNPHI) recognized the Health Across All Policies/Age-Friendly NY initiative with its 2019 Public Health Innovation Award. The award is given for an out-of-the-box solution resulting in new approaches, scalable ideas, and ways of working together. The NNPHI cited New York for strong partnerships, a strategic vision, and their innovative initiative. 70 Additional Context New York consistently outspends most other states with regard to Medicaid Long Term Services and Supports, accounting for 18 percent of total LTSS spending nationally. New York spent a total of approximately $26 billion in FY 2016 on Medicaid Long Term Services and Supports, a 20 percent increase from 2014 spending levels, and nearly twice as much as California - the second highest spending state. Despite increased spending and a general awareness of the issues affecting the delivery of Long Term Services and Supports, New York’s long term care system seems to be ill-equipped to effectively handle the challenges that come with changing demographics and a preference for older adults to age in place. 71 Long Term Care Planning Project • In order to better understand the projected and desired needs of older adults in New York, Governor Cuomo launched the Long Term Care Planning Project (LTCPP) to examine New York’s long term care system and identify existing service gaps, cost-effective evidence- based interventions, and prepare a strategic plan to meet the emerging needs of New York’s aging population over the next decade. • With participation from external stakeholders, the Department of Health and the Office for the Aging (NYSOFA) jointly lead the effort. • The LTCPP’s meeting topics were informed by a survey of professionals, care recipients, and caregivers across the State that was available from April 13, 2018 through July 27, 2018. • Overall survey responses named cost, access to services, and ability to age in place as top concerns within the aging and long term care system. 72 Survey Result Takeaways • Overall concerns included: • Costs • Access to services • Ability to age in place • Top concerns from health care providers: • Adequate staffing and low wages • Resources/funding • Rules and regulations/complexity of process • Top concerns from social services providers: • Adequate staffing and low wages • Home Care • Resources/funding • Top concerns from recipients of services/informal caregivers involved: • Cost • Adequate staffing and low wages • Family caregiver/emotional concerns 73 Please check the top five gaps in service for older adults and/or individuals with disabilities ANSWER CHOICES RESPONSES* Information and referral resources to keep older adults and/or individuals 59.16% with disabilities in their homes Timely access to home care services 58.17% Lack of communication between providers, caregivers, and other 56.64% agencies involved in a recipients care Support for caregivers 48.81% Knowledge or understanding of the needs of older adults and/or 47.82% individuals with disabilities *Percentages in table exceed 100% because respondents could choose more than one answer 74 Please check the top five concerns in relation to Long Term Care Services ANSWER CHOICES RESPONSES* Cost of services 69.91% Worry about not being able to age at home or location 55.83% of your choice Financial wellness 42.64% Worry about losing independence 39.08% Lack of resources in your community to assist with 36.66% non-medical needs * Percentages in this table exceed 100% because respondents could choose more than one answer 75 Is there any other information you would like to share about the long term care system? Top comments focused on the following topics: • Cost Concerns “Dad wants Mom home, but that would cost even more than the nursing home does.” • Staffing and low wages “It's getting quite difficult to find good home health care aids because of low wages.” • Family Caregiver/Emotional Concerns “Informal/family caregivers are undervalued, insufficient voice - particularly in health policy and relevant insights from observing those we care for.” • Accessibility “It is really hard to access the formal supports. Easier to pay out of pocket or go without … too expensive.” • Rules & Regulations/Complexity of process “New York State has done a disservice to residents by adding too many layers of service coordinators, navigators, care coordinators, etc.) which has only caused more confusion for patients and caregivers.” 76 Long Term Care Planning Project - Meetings • Survey findings indicate that more discussion is needed to address disconnects in how recipients and caregivers access information, receive services and supports, support the State’s informal caregivers, and ensure a stable workforce that can support New York’s aging and long term care needs into the future. • Accordingly, the Department and NYSOFA will jointly host several meetings with the following topics: • Improving Coordination, Communication, and the Consumer Experience; • Evidence-Based Programs and Innovative Models in Aging and Long Term Care; • Family Caregiver Support; • Supporting the Long Term Care Workforce; and • Alternative to current public programs (Medicaid). 77 Greg Olsen, Acting Director New York State Office for the Aging [email protected] Mark Kissinger, Special Advisor to the Commissioner of Health New York State Department of Health [email protected] The Growing Caregiver Shortage: From Bad to Worse Panel Moderator: Peter Strauss, Esq., Senior Partner Pierro, Connor & Strauss Beth Finkel State Director | AARP New York The Healthcare Worker Shortage & Family Caregiving In NYS Number of home health aides needed in U.S. projected to increase by 46.7% from 2016 to 2026, from 911,000 in 2016 to 1,337,000 in 2026. Need driven by aging of huge boomer generation and its increasing need for assistance. Challenges & Solutions › Lack of staff, inadequate training, insufficient number of bilingual workers and workers sensitive to different cultures. › Poor quality, physically & emotionally challenging nature of jobs makes recruiting hard. › Labor shortages in urban/suburban settings magnified in rural communities where there are fewer people available to be trained and hired for caregiving roles. AARP Supports: › Allowing direct-care workers to take on additional roles with greater compensation; › Requiring adequate staffing; › Encouraging workers’ participation in decisions on resident care; › Providing programs, career ladders, educational incentives to facilitate advancement; › Providing day care for children of staff But… Most Older Individuals Never Receive Care from a Paid Worker › Majority receive care from family caregivers. › NYS has nearly 2.6 million unpaid family caregivers who … › Provide 2.4 billion hours of unpaid care annually … › Valued at nearly $32 billion per year ($470 billion nationwide) › If you aren’t currently a caregiver, you either have been or will be one. › And at some point in your life, you may need a caregiver. Caregiving is Expensive › Avg. family caregiver spends nearly $7,000 out of pocket – 20% of their income –on caregiving every year. › Hispanic caregivers spend over $9,000 – 44% of their income; African Americans spend 34% of their income. › A NYS caregiver tax credit would help alleviate the financial strain › AARP supports S5100 May/A7209 Bronson to provide tax credit of 50% of eligible expenses up to $3,500 on a first come-first served basis. Shrinking Pool of Caregivers › About 9 in 10 NYers want to age at home - but as population ages, pool of potential family caregivers is shrinking. › In 2010, there were 6.6 potential caregivers aged 45-64 for every NYer 80+. That ratio will drop to 4.8 in 2030, & 3.5 by 2050. › That will put increasing strain on family caregivers, especially as they’re called upon to perform increasingly complex medical tasks. NYS Success So Far & Next Steps CARE Act (2015); Paid Family Leave (2016) › $15 M increase in funding for non-Medicaid in-home services for the elderly in 2019-20 NYS budget; largest in at least two decades. › Helps NYers 60 and over with basic, non-medical needs such as home-delivered meals, transportation to doctor’s appointments and assistance with bathing and dressing – thereby relieving the burden on their family caregivers. › Avoids/delays placements in costly, mostly Medicaid-funded nursing homes. › Will reduce waiting lists that number in the tens of thousands across NYS. › Nation's first ‘Private Pay’ model of care authorized as part of new state budget. › Authorizes NYSOFA to develop private pay market to increase ability of aging services network to serve more NYers of all income levels, ensure consumers can access professional, objective network of providers to help older adults remain independent. › NEXT STEPS: Urge your legislator to co-sponsor and support S5100 May/A7209 Bronson! Nora Baratto Director of Client Services| EverHome Care Advisors Home Care Challenges from the Consumer /Caregiver Perspective › Expectations of coverage & availability › Lack of on-going support and guidance in accessing care and navigating the Medicaid programs › Lack of home aides especially in rural areas › Waiting for Care to start when “in crisis” › Feel alone, overwhelmed and stressed › Health system lacks compassion pushed through the care system with no real answers Roles and Responsibilities are Unclear › Case Managers › Care Navigators › D/C planners, Social Workers This causes confusion and › Insurance Case Managers frustration, leading many › Care Coordinators caregivers to give up › Coaches › Patient liaisons Fred Erlich Founder and CEO | Living Resources Total Individuals served: 2198 Total People Employed: 883 Total Programs: 16 What Ails Agencies? Labor Shortage is Compounded by: › Rising N.Y. State Mandated Minimum Wage › Rising N.Y. State Mandated Minimum Wage for Fast Food Industry › Our profession is not widely known, understood or valued › Changing Demographics › More people retiring › Fewer Replacement Workers › Low Unemployment (3.6%) Labor Forecast: General Minimum Wage Rate Schedule Location 12/31/17 12/31/18 12/31/19 12/31/20 2021 Remainder of NYS $10.40 $11.10 $11.80 $12.50 TBD Fast Food Minimum Wage Rate Schedule Location 12/31/17 12/31/18 12/31/19 12/31/20 2021 Outside of NYC $11.75 $12.75 $13.75 $14.50 $15.00 Hospitality Workers are our Competition Source: https://hortonpllc.com/2019-new-york-minimum-wage/ Direct Support Hires October 1, 2018 – April 30, 2019 Hired 153 people for Direct Support 24% Turnover Separated 37 people Retained 116 Company Wide Staffing 1,013 Total Positions 883 Filled (675 Direct Support ) 130 Open* *all Open Positions are Direct Support Professionals as of 4/30/19 Cost of a New Hire: $3,500 $3,500 $400 Human Resources $100 Pre-Employment Human Resources – $3,000 Advertising, recruiting, interviewing, reference $2,000 checking, etc. $3,000 Paid training $2,000 Pre-employment- Physical, drug testing, etc. $2,500 Paid Training- $1,000 New hire salary, trainers salary, materials, job shadowing, etc. $500 $0 Elizabeth Martin CEO| Consumer Directed Choices What is Self-Directed Home Care? › Patient/consumer (or representative) responsible for recruiting, hiring, training, supervising, scheduling, terminating home care workers › Home care worker can be hired “off the street” or can be most family members, neighbors, friends, etc. › Examples of self-directed home care: › Medicaid Consumer Directed Personal Assistance › Office for Aging – Expanded In-Home Services for the Elderly Program › NYS Department of Health – Caregiver Support Initiative Consumer Directed Respite › Private Pay Direct Hire Is Self-Directed Home Care the Answer to the Home Care Shortage? ›Can help in the right situations: ›Individual needs to have the ability to self-direct ›Individual must be accepting of self-direction ›Self-direction is not a panacea: ›Self-direction not appropriate for all situations ›Self-directed consumers still struggle with recruitment/retention of adequate staff Self-directed Consumers Must Still Compete With Other Sectors For Staff ›2018 CDChoices Consumer Survey ›12% response rate Consumer-Worker Relationship All 1 Worker 2 Workers 3+ Workers Family member 42.86% 45.10% 30.77% 47.22% Friend(s) 27.68% 15.69% 42.31% 33.33% Boyfriend/Girlfriend 4.46% 1.96% 11.54% 2.78% No relation 53.57% 39.22% 38.46% 86.11% NOTE: Percentages add up to more than 100 due to “select all that apply” question Homecare Shortage Current & Future Challenges… › Low wages/benefits; low “respect” › Record low unemployment › Demographic trends Need for Statewide or National Strategy & Vision… › Toward Increased Workforce Numbers › Better wages/benefits › Improved societal attitudes toward home care work › New recruitment sources (retirees, college students, people w/disabilities) › Smarter immigration policies › Home Care Worker Demand Reduction/Increased Efficiency › Investments in Technology Development › Investments in Medical Advancements › Investments in Programmatic Innovations (e.g. informal caregiver supports) Al Cardillo President and CEO| Home Care Association of New York State Demographics and the Growing Demand for Home Care and HC Personnel Policy, Program, Consumer Trends: 1977 creation of PHL Article 36 and preamble establishing statewide availability and accessibility of home care to be a public policy priority More recently, DSRIP, VBP, managed care, state/federal policies, technology, efficiency goals and state of the art medical practices are leading to substantial new and future demand for care at home Home Care Personnel in High Demand but Short Supply Challenges: Staff Shortages Average Percent of unfilled in-home direct-care positions due to staff shortages 17.07% Unfilled HHA/PCA jobs 20.62% Unfilled LPN/RN jobs 20.67% Unfilled therapist jobs Challenges: Retention/Turnover Registered Nurse/ Home Health Aide turnover Professional turnover rates rates 30%- 80% 30%-58% 23.63% 28.88% 24% of home care 42% of home care Average agencies reported Average agencies reported above average RN above average home turnover rate turnover rate health aid turnover turnover rates w/ rates w/ high being the high being 80% 58% The most common reasons for staff turnover: › “Staff leaves for other sectors” › “Staff finds higher pay elsewhere” › “Paperwork and regulatory burden” Challenges: Access Average percent of monthly home care patients that are unable to access services due to labor shortages Challenges: Financial Systemic Financial Fragility throughout the Home and Community Based System 64% MLTCs in negative premium position CHHA LHCSA Hospice 72% -11.95% 65% 42% 74% -16.57% 72% Avg. CHHAS operating LHCSAs with negative LHCSAs who had to use a Hospices with negative Average operating margin CHHAS w/ negative margins in 2017 operating margins in 2017 line of credit, or borrow operating margins on net for all hospices statewide operating margins in 2017 * -7.30% in 2015 money, to stay afloat patient revenue (based on net patient * Up from 70% in 2015 (50% had negative revenue) margins on their total revenue State/Federal Responses to Shortage? Status of Budget Investments for Home Care Does this sync with: • demand for care? • consumer preference? 1. DSRIP, Transformation Hospitals • advances in medical practice? Funds, “Fidelis” Budget Pool • state/federal policy to reduce acute/ER use? • cost? • quality? vs Home Care 2. Minimum wage, advanced HHA, waivers- double edge 3. No permanent, structural solutions being proposed Cuts, Stagnant Payment, Unfunded Mandates, Inadequacy and Unresponsiveness of Payment Methodologies These present huge challenges to all home care service programs and organizations to recruit and retain essential personnel commensurate with patient need and value of personnel. HCA Proposals › CHHA, MLTC, LHCSA rate stabilization and rate adequacy proposals (S.5915 Rivera/A.7798 Gottfried, and other being introduced) › Rate adjustment for CHHA, LHCSA, Hospice, MLTC targeted to shortage disciplines and geographic areas and to allow funds to be used to pilot critical supports for personnel, such as transportation, child care, education, peer support, etc. (S.1420 Serino/A.6768 Bronson) › Competitive Labor Market Analysis, with recommendations for rate and rate methodological changes necessary to support home care workforce commensurate with need. (S.1359 Serino/A.6902 Bronson) › Interagency state initiative to promote value and interest in home care and hospice occupations and to promote entrance into the field, including from pipeline, professional schools and practice. HCA Proposals › Cross training programs (HCRA funded); include provisions to allow hospital-homecare-hospice cross training collaboratives under the HCRA Health Care Worker Retraining Program. (seeking reintroduction of S.8613 of 2018) › Home Health Aide and Personal Care Aide In-service Training and Tacking (S.5605 Rivera, A.7854 Gottfried) Data Source for Presentation HCA Report: STATE OF THE INDUSTRY 2019: Financial Condition and Trends in Home and Community-based Care Valerie Bogart Director| Evelyn Frank Legal Resources Program New York Legal Assistance Group Minimum wage/ wage parity 2018-19 Rate paid to LHCSA higher than wages in chart NYC- large employer NYC – small Westchester, Long Rest of State 11+ employees employer (< 11 Island Jan 1, 2018 Base wage $13.00 $12.00 $11.00 $10.40 Supplemental $4.09 $ 4.09 $3.22 Total $17.09 $16.09 $14.22 Jan 1, 2019 Base wage $15.00 $13.50 $12.00 $11.10 Supplemental $4.09 $4.09 $3.22 Total $19.09 $17.59 $15.22 https://www.health.ny.gov/health_care/medicaid/redesign/mrt61/2017-10-31_ww_parity_min_nyc.htm ; https://www.labor.ny.gov/workerprotection/laborstandards/workprot/minwage.shtm When is Aide paid Overtime? › Federal labor regulations used to exempt home care aides from the Fair Labor Standards Act overtime requirements › Since Oct. 13, 2015 -- Aides must be paid overtime if work over 40 hours/week or Live-In aides working over 4 days in a work week. Overtime is 1.5 “base wage” › Travel time between different clients of the same employer/ home care agency must be paid. Travel to and from aide’s home is not paid. › Some training time also must be paid › Reaction in industry to reduce hours to 40/week – some aide had been making ends meet with extra hours Live-in 24 Hour Care – 13-hour rule › Federal regulations allow live-in aides to be paid 13 hours for a 24-hour live- in shift. Aide is not paid for: › 8 hours of sleep – (5 of which must be uninterrupted, per NYS policy) › 3 hours for 3 meals/day › But if aide shows she actually worked more than 13 hours/day must be paid. › Lawsuits brought by aides in NYS challenged the 13-hour rule in live-in cases. › NY Court of Appeals decision 3/26/19 upheld the 13-hour pay rule but said that if aide did not receive the minimum sleep and meal times, employer liable for paying every hour of the 24-hour shift, not just the actual hours worked. › Ramifications of court decision unfolding – one issue is onus on aides to show they didn’t get full sleep & meal breaks… may fear losing their job or being given less desirable work assignments, etc. › Makes difficult to attract aides to work live-in shift. Andryeyeva v. New York Health Care, Inc., and Moreno v. Future Care Health Services, Inc. Show Me The Money - Who Will Pay For The Overtime + Increased Minimum Wage? › Has the state increased the monthly capitation paid to plans enough to allow for that increase? $1 billion approved in 2019 Budget. Not enough. › Are plans passing through the ↑ rates to the LHCSAs and CDPAP agencies to pay the aides? › MLTC plans must certify to DOH that home care agencies pay overtime & increased minimum wage -- but what proof is required? › Overtime requirements have resulted in plans reducing aide schedules to max out at 40 hours per week. › Do LHCSAs and plans have to approve SOME overtime so that clients can keep longtime aides, and avoid having too many aides to cover shifts? Not clear. Lunch & Networking Please visit with our Exhibitors The Financial Challenges of Aging June 5, 2019 ©2018 Genworth Financial, Inc. All rights reserved. Agenda ▪The Need ▪Currently Marketed LTCI Products ▪The Ripple Effect ▪Looking Forward 119 The Need – an Unstainable Situation An aging, unprepared consumer set strains families – across multiple generations, as well as public programs Growing Number Of Older Adults… Increasing Need For Long Term Care: ▪ 65+ Population will grow 72% between 2015 and 2040… from ~48MM to ~82MM ▪ ~50% over the age of 65 will require formal, paid LTC services High Exposure to LTC Risk, Combined With Low Preparedness/ Waiting To Address Issue Until It’s Too Late ▪ Average cost a long term care event ~$170,000. 75th percentile ~$230,000 (PwC study). ▪ Adults with an individual LTC policy: < 7% Unhealthy Finances of Near Retirees ▪ $135,000 in retirement savings, $108,000 in debt (55-64 year old Americans, national average) Rising Bankruptcies Among Senior Americans ▪ Since 2013, bankruptcy rates for age 65+ has doubled… Health Care out of pocket costs #1 driver Growing Shortage of Formal Caregivers + Impact on Family Caregivers’ Career, Finances, Health ▪ 117MM will need some form of care / assistance by 2020 versus 5MM formal + 45MM informal caregivers ▪ Self stated income lost by caregivers each year of caregiving: 33% avg. ▪ 62% of caregivers state dipped into savings and retirement funds to cover caregiving expenses -$10,000 And, Public Programs Are Severely Strained ▪ The Medicare Part A trust fund, which covers skilled nursing, will deplete in 2026 Sources: U.S. Census Bureau, LIMRA, Department of Health and Human Services, PwC Cost of Formal LTC Study, ASPE, AARP, Employee Benefit Research Institute 120 Genworth Cost of Care 2018: New York State 121 Genworth Cost of Care 2018: New York, Albany Area 122 Currently Marketed Products 123 Stand-alone Long Term Care ▪ First U.S. policies (1970’s) paid limited benefits for stays in skilled nursing facilities only ▪ Comprehensive policies emerged in late 1980’s ▪ In 1996 HIPAA defines Tax Qualification and effectively standardizes the benefit trigger (inability to perform at least 2 out of 6 ADL’s or a severe Cognitive Impairment ▪ Standard Policy Features/Options include: Elimination Period, Maximum Daily/Monthly Benefit Amount, Maximum Lifetime Benefit Amount, and an Increasing Benefit Option ▪ Once Chronically Ill, covered expenses are reimbursed although some variations pay benefits on an indemnity or cash basis ▪ Premiums are based on Issue age and are typically “intended” to be level for life – Guaranteed renewable: insurer cannot cancel as long as required premiums are paid – Premium increases require prior approval by regulators 124 Life Insurance/LTC Combination Products ▪ Often a rider attached to a permanent life insurance product ▪ The insured can accelerate (receive an advance payment of) all or a portion of the death benefit ▪ Benefit eligibility requirements are generally the same as stand-alone LTC ▪ After an elimination period, small percentage (2% - 4%) of the death benefit can be accelerated each month until the death benefit is exhausted ▪ Extension of Benefits Option: provide an additional LTC benefit once the policy’s death benefit has been exhausted (typically 2 to 4 times the death benefit) ▪ “Chronic illness” variant: – Not regulated as LTC and cannot be marketed as LTC – Agents are not required to have LTC sales training – Cannot have an Extension of Benefits Option 125 Stand-alone vs. Combo LTCI Sales 2,000 New Premium by Calendar Year ($millions) 1,800 1,600 1,400 1,200 Stand-alone LTCI Combo LTCI 1,000 800 600 400 200 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 ▪ Sales for these two product segments have moved in opposite directions since 2000. – Stand-alone sales decreased due to premium rate increases and carrier exits – Combo sales increased as carriers entered the market ▪ Note: Premiums for single premium combo products are divided by 10 here. Unadjusted sales for 2017 were $4.1 billion. Sources: 2001-2014 Broker World Surveys and LIMRA’s Individual Life Combo Products Annual Reviews 126 Combination LTCI Products – Perceived Appeal Customers Carriers Immediate Value: Mitigated risks: Death benefits and equity build up via • Exposure limited to life policy net the life insurance cash value amount at risk • Insured’s equity in base coverage acts Cost effective LTC Insurance: like a “co-pay” Add-on premium is less than stand- • Pre-funding of mortality risk offsets alone LTC Coverage morbidity risk • Decreased regulatory, reserve, and capital requirements Note: While incremental cost for the LTC is less than stand-alone LTC, the total cost of the combination is Distribution significantly higher than stand-alone Easy to distribute: LTC insurance • “Add-on” to the base policy: views the LTC component as a supplementary sale In reality, combination product sales are misleading since 75% to 95% of premium is associated with the non-LTC portion of the product. In truth, neither product is currently addressing a significant portion of the market need 127 How Are People Feeling? The Long Term Care Ripple Effect 128 Expectation: Recognition & Acceptance 6 out of 10 believe they will need long term care services in their lifetime. J&K Solutions September 2017 – sample size =1200 The Long Term Care Ripple Effect 129 Expectation: Recognition & Acceptance Almost all surveyed believe having some long term care coverage is better than none at all. J&K Solutions September 2017 – sample size =1200 The Long Term Care Ripple Effect 130 Expectation: Someone Else J&K Solutions September 2017 – sample size =1200 The Long Term Care Ripple Effect 131 Expectation: Someone Else 2 out of 3 expect government programs to partially or fully cover the costs of their long term care services. J&K Solutions September 2017 – sample size =1200 The Long Term Care Ripple Effect 132 Personal: Action 1 out of 5 42% think but do not act Majority not taking action to finance future long term care expenses. J&K Solutions September 2017 – sample size =1200 The Long Term Care Ripple Effect 133 If I’d Only Known Then What I Know Now Caregivers and recipients Over % would have done things 75 differently. Genworth Beyond Dollars Study 2018 The Long Term Care Ripple Effect 134 Top Reasons For Not Planning Didn’t want to admit care was needed Timing of long term care need was unforeseen / unexpected Didn’t want to talk about it Thought they had more time Hoped the issue would resolve itself Genworth Beyond Dollars Study 2018 The Long Term Care Ripple Effect 135 Looking Forward 136 Changes In Care Delivery Who Will Need LTC & Available Resources 8.0 7.2 7.0 6.6 6.0 5.0 4.1 4.0 2.9 3.0 WWII The Silent Baby 2.0 Generation X Generation Generation Boomers Born 1965-1980 Born 1925-1944 Born 1945-1964 1.0 Born 1900-1924 Ratio of care givers to care receivers receivers careto givers care of Ratio 0.0 1990 2010 2030 2050 • Generation receiving care will start to flip to Baby Boomers Source:• USRatio Census Bureau of 2015 Projectioncare Population givers to care receivers will drop dramatically 137 • Both will drive changes in care delivery out of Current Care Delivery → Emerging Care Delivery Who: ▪ Recipients: Baby Boomers ▪ Informal caregivers: Generation X ▪ Recipients: Silent Generation ▪ Formal caregivers: Millennials ▪ Informal caregivers: Baby Boomers ▪ Formal caregivers: Generation X Generational dynamic: ▪ Baby Boomers will demand change ▪ Will not expect help from children ▪ Silents accept how things are ▪ Will not tolerate isolation ▪ Do not want to burden children ▪ Will expect to maintain lifestyles ▪ They have busy, mobile children ▪ Emerging tech will be deployed ▪ Social isolation ▪ More efficient, less labor intensive ▪ Low tech health system Where: ▪ At home via “smart homes” ▪ Home ▪ Lifestyle preservation “places” ▪ Assisted living facilities ▪ Amenities, mobility, social interaction ▪ Nursing homes 138 Changes to Purchase Behavior Worksite ▪ Consumers like to buy insurance products through their employer under the perception that it will be… – Less expensive than the individual market – Easier to get / fewer requirements – Through an insurance company that was vetted by their employer ▪ Challenges: – General lack of interest in LTCI from younger consumers – Ease of enrollment is important, requiring simpler products and a streamlined underwriting approach Direct to consumer ▪ Online purchasing scores well as a channel preference in consumer research ▪ The more complicated the product appears, the more a consumer thinks they will have to sit down with an advisor ▪ Consumers prefer to start online to do research, and the more educated and confident they can be made online, the more likely they will buy online ▪ An online sales channel will require a simple product and a simple enrollment approach Source: Society of Actuaries Think Tank Consumer Research Study, 2018 139 Potential Government Programs Catastrophic plans (Cohen-Feder, LeadingAge, Rep. Pallone) ▪ New social insurance program (or Medicare add-on) ▪ Essentially high-deductible LTC coverage ▪ Size of deductible could be means tested ▪ Financed via small payroll tax (1% for Cohen-Feder proposal) Medigap / Medicare Advantage option (Bipartisan Policy Center) ▪ Small LTC benefits provided as an optional Medigap or Medicare Advantage feature Increased tax favorability of LTCI premiums (Bipartisan Policy Center) ▪ Use 401k to fund LTCI premiums penalty free. Some movement has occurred: ▪ Small LTC-like benefits permitted in Medicare Advantage plans (CMS 4/2018) ▪ Proposals to expand tax-favored contributions to HSAs (DOL, Treasury and HHS 12/2018) ▪ WA – Long Term Care Trust Act 140 Changes to Insurance Products Stand-Alone Product Simplification – Reducing Options ▪ Make products easier to understand ▪ Improve company risk profile Life/LTC Combination Product Refinements ▪ Attempting to design combinations to be more attractive to the middle market (recurring premium) – still expensive relative to stand-alone LTC ▪ Position combinations as LTCI solutions, as opposed to “add-ons” to life insurance sales Recent SOA Activity SOA Think Tank and NAIC Innovation Subgroup ▪ Analyzed various product and financing concepts (results available at www.soa.org) ▪ Combination Product Designs ▪ Defined Contribution Approaches ▪ Tax Favored Funding of LTC Services and/or LTC Insurance Genworth View ▪ Product Designs and Defined Contribution Approaches appear complex ▪ Tax Favored Funding of private insurance appears to be most straightforward means of incenting the purchase of private insurance 141 Conclusion The challenges of aging don’t ever affect just one person. Care cost continues to increase and is getting more expensive. Retirement and savings are at risk. American’s have spoken, they are in need of help, education, options and they need to take action. The Long Term Care Ripple Effect 142 Speaker Contact Information David O’Leary President & CEO, U.S. Life Companies Genworth Financial, Inc. 6620 West Broad Street Richmond, VA 23230 United States of America +1 804.281.6270 [email protected] 143 Community-Based Care: A Case Study Panel Moderator: Aaron Connor, Esq., Managing Partner Pierro, Connor & Strauss Meet Vera Zeromum › 83 years old › Lives in Colonie, New York Case Study Information › Recently discharged from a sub-acute rehab after stay for fall › Vera had been managing her medications appropriately. After recent hospitalization and rehab there were changes to the medications › Visiting nurse referral had been made by rehab. Vera threw out nurse due to “being told” how to take her meds Nora Baratto Director of Client Services| EverHome Care Advisors The Role Of An Aging Life Care Coordinator Comprehensive In-Home Assessment › Client’s Short and long term goals › Bio psycho-social needs, functional › limitations › Advance Directives › Current formal and informal supports › Current and future care needs › Financial, Insurance, Eligibility for Entitlement programs Assessment Findings Physical: Complex Medical Needs - Congestive Heart Failure(CHF), Diabetes, Chronic Obstructive Pulmonary Disease (COPD Functional: Ambulatory but easily becomes short of breath; poor endurance Cognitive: Alert, Oriented Person, Place and Time. Assessment Findings Home Environment: Cluttered, unable to complete routine housework Psychosocial: Isolated, depressed becoming secretive and easily overwhelmed when routine is upset Financial / Legal: Referral to Elder Care Attorney- Medicaid planning and Advance Directives; limited funds; issues with bill paying and managing funds Development of Vera’s Care Plan › Client and family goal is to remain in her own home with increased supports › Referral back to VNA and new referral to a telemedicine provider after discussion with client and family regarding need for health monitoring and new medication added ; pill packs for ease of compliance Development of Vera’s Care Plan ›Recommendation for ongoing follow up with primary care and other medical professional ›Agreed to companion services 7 days a week for 4 hours (2hours in AM/2 hours in PM) to assist with meal preparation Development of Vera’s Care Plan › Referral to Elder Law Attorney for Medicaid planning, Advance Directives and legal planning › Recommendation for companies for financial monitoring and bill paying. › Recommendation of technology solutions to enhance support and care in the home. Create coordinated communication among family and providers to have real time data and alerts regarding Vera’s care plan Ongoing Care Coordination for monitoring, ongoing support and guidance in achieving long term goal of Aging in Place. Exploration of Consumer Directed Personal Care Program (CDPAP) Frank Hemming Attorney| Pierro, Connor & Strauss Vera’s Financials Income Assets Social Security $1,069 Home $300,000 (FMV) $50,000 (HELOC balance)* Pension $500 IRA $75,000 RMD $385 Checking $10,000 Total Income $1,954/month Savings $40,000 Car Exempt Exempt Assets › Individual resource allowance ($15,450) › Home ($878,000 limit) – As long as you live there › Automobile › Prepaid burial and funeral services › Income producing property – business assets › Life insurance – face value less than $1,500 › IRA in “Periodic Payment Status” Nonexempt Assets = Everything Else Medicaid Asset Protection Trust Assets •Trustee – manages trust assets •Beneficiaries – Client – income for life and right to use real Clients property – Heirs = Remaindermen - Income inherit when trust ends Medicaid Asset Protection Trust Home Bank Accounts MEDICAID ASSET Stocks & Bonds PROTECTION SLIDE Annuities › Income is yours if you want it. Life Insurance › Principal can NOT be given Business back to you directly. Real Estate Medicaid Asset Protection Trust KEEP OUT Security Features › Choose initial Trustee, and change at Cash any time Bank Acct. › Choose initial beneficiaries, and IRA, 401(k) change at any time › With the consent of all beneficiaries, in some jurisdictions the trust can be “amended or revoked” Medicaid Asset Protection Trust Advantages: › Individual resource allowance ($15,450) › Home ($878,000 limit) – As long as you live there › Automobile › Prepaid burial and funeral services › Income producing property – business assets › Life insurance – face value less than $1,500 › IRA in “Periodic Payment Status” Nadia Arginteanu, Esq. Trust Counsel| NYSARC Trust Services Pooled Supplemental Needs Trust (SNT) › A pooled supplemental needs trust is a special type of trust in which a not-for-profit trustee, like NYSARC, agrees to hold assets for the benefit of a person with disabilities to preserve that person’s eligibility for government benefits and protect excess funds to improve their quality of life › Federal and New York State law both permit the use of a pooled SNT by persons with disabilities for the purpose of determining Medicaid eligibility by permitting the sheltering of excess income and/or resources › Funds in a trust can be used to provide for quality of life purchases that a person’s benefits do not provide Benefits of a Pooled Trust › Qualify and maintain eligibility for Community Medicaid to get health care benefits and long-term care services, like home care, without a complete loss of resources and financial independence › Utilize excess funds for living expenses and to enhance quality of life › Maintain comfort and independence in the community - get needed care at home and avoid a nursing home › Helps people transition home following short-term rehabilitation › Benefits can provide helpful relief for family caregivers Using a Pooled Trust for Income Spend-Down “Income received by an individual and placed into a pooled SNT in the same month will be disregarded for Medicaid eligibility purposes.” 2019 NY Medicaid Income Limits Individual $859/month (+$20) Couple $1,267/month (+$20) 2019 NY Medicaid Resource Limits Individual $15,450 Couple $22,800 Examples of Monthly Income: Social Security; Pension; IRA Distributions Vera: Using a Pooled Trust for Income Spend-Down Vera’s total monthly income: $1,954 Medicaid Income Limit: -$879 Excess monthly income (spend-down)* = $1,075 Administrative fee -$75 Funds left in the trust to pay bills $1,000 After the monthly administrative fee, Vera will have around $1,000 in her trust account to pay bills and other expenses *Excess monthly income is determined by Medicaid Trust Administration › All disbursements must be for sole benefit of the trust Beneficiary › Disbursements must be substantiated by supporting documentation › Disbursements can only be paid directly to third parties › Account terminates upon passing of the trust Beneficiary and no disbursements can be made after death in accordance with Federal SSA POMS policy Types of Disbursement Requests › Submit a bill/receipt to pay a third party directly › Rent/Mortgage, Utility Bill, Loan Payment, Insurance Premium, Newspaper/Magazine subscription, etc. › Submit a receipt to reimburse an individual › Groceries, clothing, or other store purchases › Make purchases using a credit card › Submit Credit Card bill and itemized receipts for purchases the trust will pay › Quote/Invoice for service or purchase › Assistive technologies, furniture, computer, home repairs, etc. What Can Your Trust Pay For? For a person receiving Community Medicaid, the trust typically pays for living expenses, such as: › Rent or mortgage, property maintenance, and taxes › Utility bills, cable, phone, etc. › Transportation/Vehicle expenses/Insurance (owned by Beneficiary) › Groceries, clothing, and other personal needs › Uncovered Medical Expenses/OTC items › Additional hours for home health aids not covered by Medicaid › Irrevocable pre-need funeral arrangement › Entertainment/Recreation Frank Melia V.P Lending | Quontic Bank Expenses of Aging In Place: ›Home Repairs (normal wear & tear) ›Accommodating wheel chairs, make home safer ›Home Health Care – Private Pay Care VERA: H.E.C.M. – Long Term Care Planning ›Income requirements - APPROVED ›Approximately $150,000 available in L.O.C. ›Pay off existing $50K H.E.L.O.C. ›Free up $230 per month (HELOC payment) ›Provide $100,000 for Long Term Care costs and home improvement to accommodate Aging in Place Elizabeth Martin CEO| Consumer Directed Choices Vera’s “Style” & Informal Network ›“Style” › Appears fiercely independent › Concerns of memory loss – may affect her ability to self- direct (needs assessment to determine if she can self- direct or not) ›Informal Network Daughter in Schroon Lake › All have potential for roles › Cousin next door in alternative self-directed › Neighbors home care Alzheimer’s Caregiver Consumer-Directed Respite Services › NYS Dept. of Health grant program: Alzheimer’s Caregiver Support Initiative › Non-Medicaid respite services › Caregiver of Alzheimer’s/dementia patient employs their own respite worker(s) › Can hire most family members, neighbors, friends, etc. › Capital Region grant lead: Eddy Alzheimer’s Services Catholic Charities and the Alzheimer’s Association of Northeastern NY › Program participants eligible for other support services as well: support groups, education, etc. Consumer Directed Expanded In-Home Services for the Elderly (EISEP) › NYS Office for Aging program; administered via local offices of aging › Eligibility: Seniors 60+ years old with ADL and/or IADL assistance needs › Non-Medicaid home care services – can be consumer-directed or agency provided › No skilled nursing tasks; can assist with medications › Consumer-directed: service recipient or their designated representative act as employers of EISEP workers › Can hire most family members, friends, neighbors, etc. › Possibility of cost share: consumer is responsible for paying portion of cost Medicaid Consumer Directed Personal Assistance (CDPA) › Medicaid-funded › Administered by a Medicaid managed care plan or county Department of Social Services › Must be eligible for home care services › Can include skilled nursing tasks › Home care recipient or their designated representative act as employers of their personal assistant(s) › Can hire most family, friends, neighbors, etc. How New Technologies are Filling the Void Panel Moderator: Louis Pierro, Esq., Pierro, Connor & Strauss Your Care. Our Commitment. Planning ahead for the care that keeps families connected Susan Vail, LMSW Life Care Coordinator Elder Law Forum | June 5th Innovative technologies improve care, increase communication and provide peace of mind Integration of technology systems to allow individuals to age in place. We have technology in the home… What do I do now? Overcoming barriers: Integrating technology in the home and the lives of seniors Old methods of managing care in the home do not work Information written in a notebook or binder can be hard to read and important information can be missed There are no way to track variations or see trends with vitals Issues when calling a loved one- “I AM FINE” or NO ANSWER! We have technology in the home… What do I do now? Overcoming barriers: Integrating technology in the home and the lives of seniors The vast array of individual options for technology in the home can be overwhelming, confusing and costly Schedulers Facetime / videos Fitbits and smart watches Often seniors are wary of new items, especially technology They don’t know how to use the technology Multiple systems that don’t speak to each other Positives of integrated technology platform from a care coordination perspective • Ability to receive real time data and alerts no • Ability to customize services to their own plan matter where people live of care • Allows seniors to feel empowered and • Technology can follow them as needs change connected and adapt • Allows seniors, family caregivers, healthcare professionals and care coordinators to communicate and manage all elements of a care plan -health, home, social, financial and legal- seamlessly • Based upon the patient’s wants and needs Solutions through Technology EverSafe StayHome NY eCaring Telemedicine Aging in Place Technology Solutions Mark Johnson, CEO Technology Components Discreet Motion Detectors Bed / Chair Occupancy Strategically Placed Sensor throughout the residence Door / window / cabinet Live Video Sensors Conferencing with your loved one The “Brain” of the Technology All in One Master Panel • The Communication hub for all technology components • Can be “Stand Alone” (just for aging in place) or dual purpose with a complete integrated Security System • 2 Way Voice and Video Capable Automated Alerts Sent Directly to Family Members and Care Providers Enterprise Solutions for Facility Based Care • Create staffing efficiencies to maintain operational costs through population management. • Offer evidence-based data to support changes in levels of care. • Provide enhanced, individualized support across the care continuum. • Leverage customized trending analysis and early detection of changes in Activities of Daily Living (ADLs) to achieve improved outcomes. • Differentiate your community in the Clinical staff uses enterprise dashboard to track trends for competitive marketplace. level of care planning. www.StayHomeNY.com Email: [email protected] Phone: 518-880-2878SS 2019 Annual Elder Law Forum Impactful Care Management How much better would healthcare be if it included real time information from the home? THE NEW HEALTHCARE LANDSCAPE Critical Focal Points Insights into Current Healthcare Systems • Seeking engagement at all levels • Integration improves outcomes – payers, plans and providers aligned in unified manner • Innovation needed to connect and communicate across the continuum • Need systemic solutions, not single point products • Limited data brings limited results • Home is where healthcare begins MEETING THESE CHALLENGES REQUIRES MONITORING PATIENTS WHERE THEY SPEND THE MAJORITY OF THEIR LIVES: THE HOME • People interact with the health system when they How Patients Spend Their Time have a medical event or for a scheduled checkup • But patients spend most of their time at home • Acutely and chronically ill patients need to be monitored every day to At Home/Outside of Healthcare System optimize treatment At the Hospital In a Physician's Office HOME IS WHERE THE HEALTH IS Most serious problems start in the home The home can be a black box for obtaining timely comprehensive patient information Current remote patient monitoring systems capture limited data with no context to drive specific responses and are cumbersome to use Caregivers and patients are not integrated in many cases to the care management process or team Critical information goes unobserved until it erupts into a hospitalization Risk scores and quality measures lag due to uncollected data If we can intervene early to address problems as they arise in the home, we can keep people out of the hospital UNIQUE INTERFACE DESIGNED FOR SKILLS OF HOME CARE WORKERS INTEGRATING THE HOME IN CARE ➢ CONNECTED: Real Time communications MANAGEMENT into and out of the home ➢ EASY INTEGRATION into existing caregiver and care manager workflows ➢ Available in MULTIPLE LANGUAGES for ease of use for care workers and patients ➢ Average response time to problem in home UNDER 11 MINUTES* ➢ PARTNERSHIPS enable universal access ➢ ROBUST PLATFORM to provide telehealth and other services Focuses care management for greatest impact * Confirmed outcome with large home care organization eCARING TRANSFORMS THE HOME INTO AN INDIVIDUALLY CUSTOMIZED REAL TIME DATA RICH ENVIRONMENT Intuitive icon-based software enables home care workers, patients and other caregivers, regardless of computer skills or English literacy, to enter comprehensive real time health care data from a variety of post acute care settings. Critical Behaviors Vital Signs* Medication Adherence Physical Health Pain Level Significant Events Mental Health * Vital Signs Obtainable with Remote Monitoring API REAL TIME, ONGOING MONITORING ENABLES EARLY INTERVENTIONS THAT KEEP PATIENTS AT HOME • Ongoing tracking of: o Medications Adherence o Physical and Mental Health o Clinical Data o SDOH o Discharge Plan Compliance • Algorithms generate customized alerts enabling early interventions • Access for all relevant parties: care managers, clinicians, family members • Increasing patient engagement and satisfaction Home Care Manager PROVEN SUCCESS WORKING WITH MANY KINDS OF PATIENTS LTSS Dual Eligibles $500 PMPM 35% Reduction in Cost Savings Hospital, ER Use, MD visits Hospital/Medical Center 35% Reduction in CHF Readmission Rate Managed Long Term Care $3,000-$10,000 >4x Annual Savings PM ROI $400 PMPM 54% Reduction in Medicare Advantage Plan 17% Reduction in Length of Stay Medical Expense A SINGLE INTEGRATED SYSTEM FOR ALL DISEASES AND CONDITIONS • One system for post-acute, post- procedure and chronic care management • Customized data, alerts manage care, stratify risk on population, condition, disease and individual level CHF • Ongoing monitoring and COPD longitudinal records for quality, Diabetes performance documentation, and Asthma engagement CHF, COPD, Diabetes, Asthma, Dementia Panels; Can create new customized data sets on demand SmartPOC™: EASY SYSTEM TO ASSIGN POCS TO PATIENTS • Determine plan of care requirements based on health risk assessments, diagnoses, clinician input • Select or establish POC with provider: • General • Condition specific, e.g., CHF, Diabetes, COPD, asthma, dementia, post-surgery • Integrate input from other sources: EMR, CMS, assessments, etc. • Match and assign patient to POC • Customize POC at individual level as appropriate • Ongoing review and modification based on unique real time data from the home as patient status and Develop, Integrate, Monitor and Ongoing Revise of POCs conditions change. ROBUST ANALYTICS AND REPORTS INSURE TIMELY AWARENESS, EFFECTIVE RESPONSES AND IMPACTFUL REPORTING ➢Reports Include: ➢ Alert and Notification Outcomes by CareManager ➢ Observations ➢ Aide Activities ➢ Alert Interventions ➢ Notes/Observations/Alerts ➢ Logins, Schedules and Workshifts ➢ Quality Metric Tracking ➢ Time to Alert Intervention ➢ Time to Close Alert ➢ EVV Integration Care, for Life Join us in helping keep patients out of the hospital and in their homes. For more information, please contact our CEO at [email protected] VIRTUAL EMERGENCY MEDICINE WHERE POPULATION HEALTH STARTS Keith Algozzine, CEO PROPRIETARY & CONFIDENTIAL “I thought I was dying and I needed to go to the E.R.” Health insurers refused to pay the medical bill citing his care in the ER was not needed. - Jason Salyers, of Ashland, Ky. From nytimes.com on May 19, 2018 photo by Luke Sharrett for The New York Times “Don’t Punish People For Using The ER” Boston Globe, December 2014 PATIENTS NEED ER SERVICES ER utilization can only be solved by bringing the ER to them PAYERS NEED AN ALTERNATIVE Payers need a new modern day version of the ER to meet patient demands PROPRIETARY & CONFIDENTIAL Introducing UCM ALIGNING THE PATIENT, PAYER & PRIMARY CARE • 24/7 immediate triage & treatment by the UCM ER team • Take all acute problems and exacerbations of chronic disease • Actionable data collection and analytics • Improved quality, reduced cost & life saving UCM Virtual ER Patient Experience PROPRIETARY & CONFIDENTIAL Statistics Back Up The UCM Story Patient Average 98% Satisfaction 60%+ Utilization PROPRIETARY & CONFIDENTIAL VIRTUAL ER SPECIALISTS BACKGROUND: Assist health systems to meet regulatory and community demands of providing victims of sexual assault the highest quality care and receive justice by helping collect this critical evidence properly. We provide 24/7 TeleSAFE ER experts that can guide any provider at any location through this specialized forensic medical exam. USE CASES: In 2018 launched first large partnerships with NYS DOH and OVS along with St. Peters Health Partners to bring our expertise to 46 rural hospitals in Upstate NY. OUTLOOK: Expanding to additional health systems and additional states using the states with the greatest regulatory pressure to guide or expansion. PROPRIETARY & CONFIDENTIAL THANK YOU! CONTACT INFO: Keith Algozzine, CEO, [email protected] PROPRIETARY & CONFIDENTIAL In Development: VivaLynx App www.vivalynx.com 2019 Elder Law Forum • Questions? • Please turn in your Surveys • Social Workers – turn in forms • Thank you for joining us! • See you next year!