State Identified ILS IMD Presentation

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State Identified In-Lieu-of Services (ILS) Request Form Procedure for Institutions of Mental Disease (IMD)

Webinar with MMCOs

October 2021


Purpose

  • To learn how to submit an application for State budget initiative Medically Tailored Meals (MTM) ILS coverage permitted under 2016 Final Rule, 42 CFR 438.6(e)

Agenda

  • The New York State (NYS) FY 2020-21 budget authorized the State Department of Health (DOH) to establish three pilot programs in one or more counties or regions of the state for the purpose of promoting social determinant of health interventions. These pilots include:
    • pilot that provide medically tailored meals to high-needs individuals;
    • medical respite pilots that provide care to homeless patients who are too sick to be on the streets or in a traditional shelter but not sick enough to warrant inpatient hospitalization; and,

    • street medicine program to better serve the chronically homeless population.

Impact of Medically Tailored Meals

Seth A. Berkowitz, Jean Terranova, Caterina Hill, Toyin Ajay, Todd Linsky; Meal Delivery Programs Reduce the Use of Costly Health Care in Dually Eligible Medicare and Medicaid Beneficiaries, Health Affairs, Vol. 37, No. 4, April 2018

Home delivered MTMs will be available to individuals 18yrs or older, living with severe illness through a referral from a medical professional or healthcare plan. Meal plans will be tailored to the medical needs of the recipient by a Registered Dietitian Nutritionist (RDN), and designed to improve health outcomes, lower cost of care, and increase patient satisfaction.

  • Eligibility:
    • High-volume service utilizer with at least one of the following diagnoses: cancer, diabetes, heart failure, and/or HIV/AIDS; or
    • Limited in ability to perform ADLs
    • Recommended for MTM by a healthcare provider or MMCO
    • Must have a secure place to store and heat meals
    • Must be able to benefit from the MTM intervention to improve overall health
  • Target Area: MTM service will be offered in full Medicaid Managed Care Plan (MMCP) service area

MTM Allowed In Lieu of Service

Medically Tailored Meals will substitute for one of the following:

  • Personal Care Aide (PCA) service - PCA hours allotted for meal preparation and food shopping may be substituted for delivery of Medically Tailored Meals (MTM). Members who opt in to receive MTM in lieu of meal preparation and food shopping hours will incur a reduction in the number of PCA hours they receive. The hours reduced will depend on the number of meals the individual receives.
  • Hospital Inpatient stays and/or Emergency Department visits - high-volume service utilizers with hospital inpatient stays and emergency department visits related to cancer, diabetes, heart failure, and/or HIV/AIDS. High service utilization being defined as:
    • Two or more Hospital Inpatient stays related to cancer, diabetes, heart failure, and/or HIV/AIDS within the last 12 months; or
    • Five or more Emergency Department visits related to cancer, diabetes, heart failure, and/or HIV/AIDS within the last 12 months; or
    • One Hospital Inpatient stay AND four Emergency Department visits related to cancer, diabetes, heart failure, and/or HIV/AIDS within the last 12 months.
Services:

MMCO will provide the following:

  • Identify plan members who meet pilot eligibility as described above
  • Provide outreach to members to determine interest in receiving MTM as an ILS
  • Facilitate plan members opt-in to services, including obtaining MD orders(if referral came from provider)
  • Refer plan members to MTM provider
  • Authorize up to 3 meals/day for six months period, with ability to reauthorize based on member reassessment and need
  • Collect and report member level information on a quarterly basis, for the purpose for tracking MTM utilization and evaluation
  • Participate in pilot evaluation activities led by DOH

State Identified ILS for MTM 42 CFR 438

The 2016 Federal Rule 42 CFR 438.6(e) permits the State to offer Medically Tailored Meals as an in lieu of service

Applies to Medicaid members,18yrs old and over who meet eligibility requirement

ILS must be cost effective alternative service, medically appropriate, voluntary for the MMCO to provide, and voluntary for the enrollee

DOH developed State Identified MTM ILS Request Form


Request Form Introduction - MTM ILS Form

  • Same request form as ILS. However, Section Two has been completed by the State.
  • To apply for and establish Medically Tailored Meals ILS coverage authority, MMCOs MUST complete Section One of the attached State Identified ILS form and submit with the following:
    1. 30-day member notice
    2. Member handbook insert
    3. Updated policies and procedures
    4. A detailed statement of how the Plan will monitor and report usage of the ILS service, and
    5. Termination requirements relating to these services.

MMCOs should complete page 1 with specific MMCO information.

Please fill in all boxes.

  • Date of the request
  • MMCO plan name
  • Contact person
  • Title of the contact person
  • Phone number of contact person
  • Email address for the contact person

Section One should be filled out by the MMCO.

  • ILS to be Provided
    Medically Tailored Meals(MTM)
  • NYS Authorization Number
    Leave blank - State will issue
  • Expected start date for provision of service
    MMCO Anticipated Start date
  • Target area for availability of service
    List service area included
  • Related to DSRIP/VBP?
    No

MMCO Monitoring Activities - Please describe in detail activities, reports, and/or analyses the MMCO will use to monitor the provision, utilization, quality, cost-benefit, and/or outcomes of the ILS.

  • Monitoring Activities include:
    • Current MMCO Utilization Management Process
    • Current MMCO Encounter Data Review Process
Proposed In Lieu of Service
A. Service Name Medically Tailored Meals (MTM)
B. Description of service, including which State Plan service this may be offered as a substitute for Home delivered MTMs will be available to individuals 18yrs or older, living with severe illness through a referral from a medical professional or healthcare plan. Meal plans will be tailored to the medical needs of the recipient by a Registered Dietitian Nutritionist (RDN), and designed to improve health outcomes, lower cost of care, and increase patient satisfaction. MTM services will include an initial intake with an RDN and nutritional therapy to discuss meal composition. Medically Tailored Meals will substitute for one of the following:
  1. Personal Care Aide (PCA) service – PCA hours allotted for meal preparation and food shopping may be substituted for delivery of Medically Tailored Meals (MTM). Members who opt in to receive MTM in lieu of meal preparation and food shopping hours will incur a reduction in the number of PCA hours they receive. The hours reduced will depend on the number of meals the individual receives
  1. Hospital Inpatient stays and Emergency Department visits – high service utilizers with hospital inpatient stays and emergency department visits related to cancer, diabetes, heart failure, and/or HIV/AIDS. High service utilization being defined as:
    • Two or more Hospital Inpatient stays related to cancer, diabetes, heart failure, and/or HIV/AIDS within the last 12 months; or
    • Five or more Emergency Department visits related to cancer, diabetes, heart failure, and/or HIV/AIDS within the last 12 months; or
    • One Hospital Inpatient stay AND four Emergency Department visits related to cancer, diabetes, heart failure, and/or HIV/AIDS within the last 12 months.
C. Proposed procedure code(s) defining service HCPCS Code S5170 – home delivered meal, including preparation; per meal
D. Is this ILS related to a DSRIP project or VBP contract? No. This ILS is being issued as part of MRTII SDH pilot program. The purpose is to promote social determinant of health interventions.
E. Expected start date for provision of service MM/DD/YYYY
F. Target area for availability of service, or where indicate ILS will be offered in full MMCP service area. ILS can be offered in full MMCP service area.
G. Assessment of capacity to provide this service within each target area MMCOs must partner with an organization that has the capacity to prepare and deliver meals according to Food is Medicine Coalition (FIMC) MTM nutritional standards, to individuals in their homes under the supervision of a Registered Dietitian Nutritionist (RDN). The contracted provider must have experience providing Medically Tailored Meals; infrastructure to perform necessary tasks and services, including tracking service delivery, and data collection.
  • The State Identified ILS Request Form will be transmitted to MMCOs via email.
  • The State Identified ILS Request Form can also be downloaded from the DOH website at:
  • ILS Launch Date: January 1, 2022
  • MTM ILS application will be accepted on a rolling basis. Completed request forms should be sent to: ILS@health.ny.gov and SDH@health.ny.gov
  • Up to 90 days review period for ILS form and supporting documents
  • MTM services are expected to begin at the start of each quarter: Jan. 1, April 1, July 1, Oct. 1.

Submit Completed Forms to: ILS@health.ny.gov and SDH@health.ny.gov

  1. MMCOs will monitor MTM services as described in the ILS request form
  2. MMCOs will report expenditures for MTM on the MMCOR as ILS
  3. MMCO will be required to submit patient level information using template provided by the State, on a quarterly basis

Table 21A-IN LIEU OF SERVICES - UTILIZATION (MEDICAID & HARP)

  • In Lieu of Services are defined as alternative services or settings that are not included in the State Plan but are medically appropriate, cost- effective substitutes for covered services or settings. In Lieu of Services require prior approval by DOH through an application process.
  • The services and authorization numbers entered on Table 21 will carry over to Table 21A. The utilization amounts for each of your entered services are to be broken out by premium group.
  • Cost and Utilization for this MTM ILS should be reported on Medicaid Tables 21 and 21A and HARP Tables 21 and 21A (Tables 23 and 23A for SNPOR).

Tables 6 & 7-STATEMENTS OF REVENUE AND EXPENSES - Medical Expense Line

  • Line 0049 In Lieu of Services - Medicaid, HARP, HIV SNP - cost of alternative services or settings that are not included in the State Plan but are medically appropriate, cost-effective substitutes for covered services or settings. In Lieu of Services require prior approval by DOH through an application process. For the HARP line of business, the information will populate from Table 21.

MMCOs submit ILS request forms and required documents on Slide 11

DOH approves ILS

Appendix M executed by DOH

MMCOs post ILS availability on their respective websites

DOH posts ILS availability on DOH website

Questions?

Submit to: ils@health.ny.gov