Different MLTC Plan
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2019 Elder Law Forum June 5, 2019 Thank You to our Gold Sponsors: Housekeeping › Please stop by our 16 exhibitor tables during the breaks today › Licensed Social Workers: Visit the CE credit table near registration to sign up to receive 6 CE credits. Be sure to hand in the accompanying form at the end of the Forum › Visit www.pierrolaw.com/resources to view all of todays PowerPoint presentations and related materials › Please complete the blue survey sheet › WiFi password- CenturyHouseWireless › Share your day on twitter using #ELF2019 Live Interview With Lawmakers: New York State Legislative Initiatives 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 <Employer 11 Westchester, Rest of State employees11+ < 11 Long Island employees Jan 1 2018 Base wage $11.00 $10.50 $10 $9.70 Base wage $13.00 $12.00 $11.00 $10.40 Benefits 4.09 $ 4.09 Supplemental $4.09 $ 4.09 $3.22 Total $15.09 $14.59 Total $17.09 $16.09 $14.22 compensation 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/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.