FAQ on the BIP MLTC Expansion Bonus Program

Responses to Plan Questions and Comments

October 24, 2014

  • FAQs is also available in Portable Document Format (PDF)
1. Can plans submit applications for multiple counties?

Yes, as indicated in the Program Description, plans may submit applications for multiple counties. However, please note that the first two Bonus Payments are per plan, while the third Bonus Payment is per County.

2. And is it possible for a plan to be awarded BIP funds in one county but not another?


3. Plans believe it will be difficult to enroll twenty–five members within three months of initiating an expansion into a new county. Could this timeframe be pushed to six months to allow for adequate marketing, referrals, and network expansions?

The timeframe cannot be extended due to limitations on the BIP funding. However, please note that counties that are projected to have the fewest "eligible" members have been grouped for purposes of calculating bonus payments.

4. Similarly, plans are concerned that there may not be enough Maximus staff to implement conflict–free assessments in rural counties, which could impede enrollment and prevent plans from reaching the target enrollment. Will the Department take any potential delays caused by the conflict–free enrollment process into account when considering whether a plan has reached the enrollment targets?

The Department is anticipating that there will be adequate Maximus staff in place to implement conflict–free assessments in rural counties. If Plans encounter delays in the conflict–free enrollment process that impede enrollment of new members under this program, they should communicate this information to Karen Ambros, BIP Program Director.

5. Plans have faced a great deal of difficulty in setting up adequate networks for the counties included in the BIP program due to a lack of willing providers. Would the Department be willing to allow plans to establish regional networks, given the scarcity of providers?

Plans hope to establish regional networks that encompass the counties identified in the BIP application. Can a plan use a regional/multi–county network to show network adequacy for the county they are applying for in the BIP application, with the understanding that they will not receive BIP funding for the counties not designated in the BIP application?

Yes, plans may use a regional/multi–county network to demonstrate network adequacy.

6. Plans have noticed that DSS staff in rural counties aren´t familiar with the MLTC product, which has made enrollment difficult. Could the Department work with DSS in these counties to make sure that they are current on the MLTC product?

Yes, the Department has and will continue to communicate information about the MLTC product to DSS staff in rural counties.

7. If a plan submits an LOI for the Bonus Incentives Program, would it be committing to submitting an application, or can the plan choose to withdraw the intent after submission?

Yes, plans may withdraw the intent after submission; however, if the first payment had been issued prior to the plan withdrawal, DOH may claw back some or all of that payment depending on its evaluation of the effort put forth by the plan.

8. Our feedback is that expanding into Region 4 counties will be unsustainable, even with this incentive, if premiums are not raised to cover likely costs. Basing Region 4 premiums on FFS costs is faulty logic because of the traditional lack of FFS care at levels approximating what MLTCPs and PACEs are expected to provide. That historical lack of appropriate levels of FFS HCBS is a key reason that nursing home utilization upstate is much higher than it is downstate. To encourage plans to not only go into, but remain in, Region 4 counties, DOH might consider basing premiums similarly to LTHHCP rates (e.g., 75% of SNF costs). That would be a better approximation of the cost of caring for NHCs in the Region 4 communities and would also serve to disincentivize use of SNFs.

This comment is beyond the scope of the MLTC expansion bonus program, however, NYSDOH has in the past promulgated premium rate adjustments to support MLTC expansion Upstate, including rural areas, and will continue to consider such adjustments to further support Care Management For All and the expansion of the MLTC program statewide. Feedback will be taken into consideration.

9. The document mentions claw back twice and the two comments seem to state different criteria for claw back to occur. Page three of the Program Description states "NYSDOH reserves the right to claw back any bonus payment made to plans upon determination that the applicant did not actively pursue completion of the milestones in a good faith effort". On page one, there is a comment that states "Plans that have not reached the enrollment level by 9/1/2015 will be subject to claw back of the initial and second payment as set forth in the milestone tables". First, what criteria constitutes a good faith effort? Second, plans can make every effort possible and still not make the milestones on minimum membership after 3 months. According to the first comment, I would think that the good faith effort was there, and plans should be allowed to keep their bonus payments, according to the second comment, all payments would be clawed–back.

Program documents have been updated to consistently reflect the intent of the program: NYSDOH reserves the right to claw back any bonus payment made to plans upon determination that the applicant did not actively pursue completion of the milestones in a good faith effort.

Good faith effort would be demonstrated through documentation of the plan´s active effort to establish a provider network, market the program to eligible prospective members and relevant stakeholders, submit a reasonable application, and other actions necessary for the plan to establish itself in the target county or counties. In addition, plans are encouraged to identify, in response to question (i) in the Letter of Intent, potential risks to meeting the requirements for a successful enrollment process and how the plan will work to mitigate these risks. This information will also be considered when assessing good faith effort.

10. My last comment/question is to confirm that the BIP bonus payments are per county, not per plan, because if a plan doesn´t meet the 25 criteria in one of the counties they apply for, the entire bonus payment would get clawed–back under that scenario.

Bonus payments one and two are per plan. The third and final payment is per county according to Attachment #2 of the Program Description.

11. One last thing to note/inquire related to this process…a plan should be allowed to submit an application for expansion into a BIP bonus program eligible county prior to submitting the letter of intent for expansion under BIP bonus program and still be eligible for the bonus (meaning submit an expansion application in the next few weeks and still be eligible).

Rephrase the question: Do Plans that are already in the process of developing an application for an expansion which would otherwise qualify for this program have to wait until their Letter of Intent is submitted and approved before submitting their application for expansion?

No, but in order to qualify for the Initial payment the Letter of Intent needs to be submitted and approved, and the second payment would still depend on the approval of the application.

The term of the program is 10/1/2014 through 9/30/2015.

12. The state should waive the requirement that plans have membership in all approved counties before being approved in new ones. Currently, the state will not approve a plan's request for expansion into a new county if the plan has approved counties without membership. As previously stated, it takes time for plans to build enrollment in new territories. Plans should be permitted approval for expansion into BIP counties if that plan has counties in its service area with no membership.

The Department will consider a Letter of Intent from a plan which has a county in its service area with no membership. However, a plan which falls into this category should provide an explanation in its response to the Request for Letter of Intent which provides sufficient information to evaluate the plan´s ability to successfully implement an additional service area expansion under this program.