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Overview of New York's Demonstration to Integrate and Manage Care for Individuals Eligible for Medicaid and Medicare

The State is preparing a draft proposal for a joint state and federal demonstration to test full integration for dual eligibles. The draft proposal will be published for public comment on March 22, 2012.

The State believes that this effort would achieve a number of significant policy goals including:

  • The "triple aim" objectives outlined by the Centers for Medicare and Medicaid Services (CMS) of improving the patient care experience; improving the health of populations; and reducing the per capita cost of health care.
  • Eliminating unnecessary and cumbersome barriers to accessing care that are inherent in the current bifurcated insurance system for the state's most needy population.
  • Creating opportunities for providers/payers for improved outcomes as system efficiencies are achieved and quality benchmarks attained.

Under this demonstration, those full-dual eligible individuals residing in the eight counties of Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, and Westchester will be passively enrolled into a fully-integrated managed care plan. Individuals will be able to opt-out of that Medicare plan enrollment and choose a different fully-integrated plan that operates in their county or participate in fee-for-service Medicare. Each county will have a choice of at least two fully-integrated plans. Individuals will be aided in their enrollment decisions by an Independent Enrollment Broker.

Enrollment will be in phases, with dual eligibles who are enrolled in Managed Long Term Care being passively enrolled for January 2014 and all remaining full dual eligibles being passively enrolled starting in January 2015. Dual eligibles under the age of 21, those receiving services through the Office of Persons with Developmental Disabilities waiver, and those receiving services in an Office of Mental Health facility would not be eligible to participate. At the outset, the New York State Department of Health (NYSDOH) proposes to build its fully-integrated program from the mandatory Medicaid Managed Long Term Care program. NYSDOH believes this holds the least possibility of disruption in access to care because so many of the MLTC plans either are integrated Medicare and Medicaid plans or are well-positioned to offer an integrated Medicare and Medicaid plan.

The State proposes the following:

  • NYSDOH will expand the service package (beyond that currently provided by Medicaid Advantage Plus plans). Among other things, the service package will include many of the services offered by the state's HCBS Waiver programs, wellness counseling, , consumer-directed personal care, and telehealth.
  • Plans will be required to provide care coordination to all participants using an interdisciplinary team approach.
  • Participating plans will be required to conduct consumer feedback sessions and either have a consumer advisory committee or have participants serve on their board of directors. Additionally, NYSDOH would conduct consumer quality surveys annually (instead of bi-annually, as is presently done).
  • NYSDOH will establish network adequacy and provider access standards – requiring a choice of every provider type and articulating both time and travel distances standards as well as appointment wait time standards.
  • NYSDOH will establish annual improvement targets for all plans. Target areas would include, but not be limited to: avoidable hospitalization; reduced readmissions; use of advance directives; and quality of life.

More details of the proposed demonstration will be made available during the pre-proposal webinars on March 13, 2012 and March 15, 2012. The draft proposal will be posted on the NYSDOH website and e-mailed to stakeholder groups on March 22, 2012 with comments due back to NYSDOH by April 20, 2012.