Plugged Into Health @ Hinman Straub – June 18, 2018

Legislative Update: End of Session

The Legislature is scheduled to wrap up the 2018 legislative session this week. The Legislature will be in session on Monday, June 18 through Wednesday, June 20, 2018.  The Senate introduced a number of bills over the weekend as there is the usual flurry of activity heading into the final week.

Bills of interest that were introduced over the weekend include:

• S.9077 (Hannon): This bill would amend the Insurance Law to provide that when an insured assigns a benefit to a health care provider for emergency services, the health care provider shall submit claims to the plan and the plan shall bill the provider directly.  The bill would prohibit the provider from billing the insured any amount other than the applicable copayment or deductible, and any payments received by the health care provider that the patient was not obligated to pay would be returned to the patient.
• S.9083 (Marchione):  This bill would redefine “eating disorder” under the Public Health Law to provide that insurers are required to provide coverage for treatment of all eating disorders under the Diagnostic and Statistical Manual of Mental Disorders (“DSM”) at Comprehensive Care Centers for Eating Disorders
• S.9100/A.9576-B (Hannon/Gunther): This bill would establish a statewide drug take back program for the safe disposal of drugs.

VBP Updates

Updated 2018 VBP Reporting Requirements Technical Specifications Manual

The Department of Health has updated the 2018 Value Based Payment (VBP) Reporting Requirements Technical Specifications Manual. The changes added to reporting requirement include a field that identifies the VBP Contractor Tax Identification Number (TIN) for each member attributed to a VBP arrangement.

The Manual is intended to make stakeholders aware of the quality measure reporting requirements for Medicaid Managed Care Organizations (“MCOs”) participating in the VBP program. The document includes an overview of the specific reporting requirements for Category 1 measures for each VBP arrangement, a description of the changes to the measure sets from Measurement Year 2017 to 2018, and detailed instructions regarding additional file specifications required for the VBP program.

Social Determinants of Health and CBO Contract Template 

At the managed care policy and planning meeting, Ryan Ashe mentioned that the State is still working to develop a new template to review SDH and CBO requirements required for VBP Level 2 and 3 contracts. The new template will include questions about the specific SDH interventions included in the contract, and the role and level of the CBO selected.

 Increasing Provider Adoption of VBP 

At the managed care policy and planning meeting, DOH asked plans to provide them with information about providers who are not engaging in VBP. The State is also requesting cost information to determine the impact these “slow moving” providers are having on plans’ abilities to meet their Roadmap targets. The State intends to use this information to help them better understand where the impediments are and to inform follow up discussions. One plan commented that they preferred not to name these providers in writing, and that the State’s outreach should focus on getting providers to accept downside risk and not just Level 1 upside only arrangements. The State has also discussed using downward adjustments to MMC FFS acute care benchmark rates for providers that are not “adequately engaging in VBP arrangements”.  

DOH Webinar on MACRA Alignment with Medicaid VBP

On Wednesday, DOH hosted a webinar to discuss the MACRA Quality Payment Program (QPP) and opportunities for alignment with NYS Medicaid VBP. The QPP has two tracks for eligible clinicians (includes physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists billing more than $90,000 a year and providing care for more than 200 Medicare patients a year) that may be aligned with NYS Medicaid. These tracks are (1) the Merit-based Incentive Payment System (MIPS), in which eligible clinicians earn a performance-based payment adjustment determined by scoring across 4 performance categories; and (2) the advanced alternative payment model  (APM), requiring either a certain number of Medicare beneficiaries or a combination of Medicare and “other payer advanced APMs” that are qualified by CMS. Clinicians that qualify for APMs are exempted from MIPS.  Qualification for the APM track under the other payer option will begin with QPP performance year 2019.

Specific alignment topics discussed include:

• Certified Electronic Health Record Technology 2015 edition (CEHRT): The MIPS track includes measures focused on patient engagement and use of CEHRT to exchange health information. The Advance APM requires this be used by 50% of contracted providers.  The NYS VBP Roadmap is silent on CEHRT but at last month’s VBP Workgroup meeting the State said they would consider incentivizing its use to increase adoption.
• Quality Measure Alignment: In MIPS, clinicians must select at least one outcome measure from 6 quality measures.  According to DOH, there are 20 category 1 measures in the TCGP arrangement that overlap with the MIPS list, including two outcome measures.  Webinar participants asked for the list of those measures that crosswalk with the MIPS list.

·         Other Payer Advanced APM Financial Risk Requirements: In addition to CEHRT, and the incorporation of MIPS comparable quality measures, to qualify as other payer APM, a VBP contract must meet the requirements for “financial risk” which fall in between NYS Medicaid’s VBP Level 2 and Level 3. Specifically, the other payer Advanced APM contractor must take on 30% of the losses (greater than VBP Level 2’s 20%), with a cap of 3% of the target budget (comparable to the existing Roadmap), and actual expenditures must exceed the target budget by 2% to trigger the shared loss repayment requirements, to qualify.  NYS Medicaid Level 3 arrangements would automatically meet the financial risk category.  Notably, it was mentioned the expenditures counted include pharmaceutical expenditures.  The VBP Roadmap currently excludes high cost drugs from VBP contracts.

Managed Care Policy and Planning Meeting

The Department of Health recently held the monthly Policy and Planning Meeting with the State’s Medicaid Managed Care plans.  Some highlights from the meeting include:

• Mainstream Enrollment: Statewide enrollment for May was 4,427,830, a decrease of 194 members since April (4,428,024), with 2,595,805 in NYC and 1,832,025 Upstate. This resulted in a statewide decrease of less than .01%.
• MLTC Enrollment: Now at 227,420, an increase of 2,790 from last month (224,630), as MLTC enrollment continues to outpace projected enrollment.  Virtually all new enrollment continues to be in the partially capitated program, which has 206,438 members compared to 204,025 one month ago and 202,513 members two months prior.  PACE enrollment grew by 24 members (5,678 vs. 5,654), snapping three months of consecutive declines. Enrollment increases also continued in MAP (10,489 vs. 10,164) and FIDA IDD (888 vs. 818). FIDA was the only program to experience a decline in enrollment this month (3,927 vs. 3,969).
• HARP: Statewide HARP enrollment with capitation paid as of June 1, 2018 is 110,962, with 57,836 in NYC and 49,029 ROS.  HARP enrollment is now available on the NYSoH as of June 1, 2018.  Plans should expect to see HARP passively enrolled HARP member transactions for enrollment begining August 1.
• FIDA: More information on the future of the integrated care product in NYS is expected to be provided later this month, though an update was supposed to be forthcoming now for several months.  DOH said three more plans are not renewing FIDA for CY 2019.  The list of plans continuing to participate will be shared when it becomes final.
• Community First Choice Option (CFCO): DOH will reconvene the CFCO Workgroups following the issuance of updated guidance for authorizing ADL, IADL, and/or health-related tasks.
• MLTC VBP: DOH said they have received mostly positive feedback about their new Level 2 strategy for MLTC partial cap.  The state is working on FAQs and a one-pager that will be sent to plans.
• Fiscal Intermediary Advertising Review and Approval: DOH will be issuing guidance shortly to FIs to reinforce provisions in the 2018 Budget that prohibit FIs from publishing misleading or false advertising.  The guidance will minimally require all FI advertising to be reviewed and approved by DOH before use, set forth permitted/impermissible activities, and explain the submission and review processes.

LHCSA Contract Limitations: DOH expects to release additional guidance on this topic soon.

Nursing Home Heat Advisory

The Department of Health recently issued a Dear Nursing Home Administrator Letter (DAL NH 18-03 Heat Advisory) to remind administrators of the effects of extended periods of high temperatures that often accompany the summer months. Residents with a history of dehydration, cardiovascular and/or pulmonary disease are particularly susceptible to heat related illnesses and complications. The DAL includes a list of signs, symptoms and consequences of heat prostration, heat stroke and heat cramps that staff members should be alert to during hot and humid weather.

Deadline Extended: Social Determinants of Health Innovation Application

The Office of Health Insurance Programs (“OHIP”), Bureau of Social Determinants of Health, has extended the deadline for applications for the Social Determinants of Health Innovation Initiative. The deadline for applications is now June 29, 2018 at 5:00 p.m.

The Social Determinants of Health (“SDH”) initiative to identify innovative ideas to effectively address the Social Determinants of Health (“SDH”) for Medicaid members across the state.  The “Call for SDH Innovations” solicits input from interested parties across the state and around the country.  Innovations will be reviewed by a team of healthcare experts identified by DOH.  While top innovations will receive special recognition, all innovations, with the consent of the submitting organization, will be shared publicly by DOH.

There is no funding from the State available for this initiative.

Age-Friendly Health Systems Webinar

As part of the Governor’s 2018 State of the State, he included a goal for New York to have 50 percent of its health systems age-friendly within the next five years.  To kickoff this project, the Department of Health, will be hosting an Age-Friendly Health Systems webinar on Wednesday, June 20 from 3:30 p.m. to 4:30 p.m.

The webinar will cover:

• What an Age-Friendly Health System is and why they are important
• The John A. Hartford Foundation and the Institute for Healthcare Improvement Age-Friendly Health Systems Initiative
• How organizations can take steps to become age-friendly

To register for the webinar, click here.

OSC Audits Managed Care Premium Payments for Recipients with Comprehensive Third-Party Insurance

Last week, the Office of the State Comptroller (“OSC”) issued a report of a recent audit designed to determine whether the Department of Health made Medicaid mainstream managed care premium payments on behalf of individuals who had comprehensive third-party health insurance (“TPHI”) coverage. According to Departmental policy, individuals who have concurrent comprehensive third-party health insurance are not eligible for mainstream managed care. Furthermore, the Medicaid Managed Care Model Contract allows the State to retroactively disenroll recipients from managed care and recover premiums paid to the MCO for those recipients during the period of overlapping coverage recipients when the Medicaid managed care provider and the comprehensive TPHI provider are the same.

The audit found that the Department paid about $1.28 billion in Medicaid managed care premium payments on behalf of enrollees who also had concurrent comprehensive third-party health insurance coverage.  Of the $1.28 billion,

• $26.9 million (about 73,000 premiums) can be recovered because the recipients’ MCO is the same legal entity as the recipients’ third-party commercial insurer.
• $70.6 million (about 191,000 premiums) were paid to MCOs that were related to the commercial insurer through some form of ownership (such as parent, subsidiary, or affiliate) to the third-party insurer.
• $1.17 billion (about 3.2 million premiums), representing about 91% of the $1.28 billion, are not recoverable because the MCO and third-party insurer are not related.

Since the majority of improper payments ($1,17 billion) found in the audit  were unrecoverable due to Model Contract limitations, the Comptroller recommended that the Department amend the Model Contract language to allow the Department to recover premiums from all MCOs regardless of the relationship with recipients’ third-party insurer.  According to the report, Department officials stated they are already considering changes to the Model Contract that would impact the types of recoveries that could be made.

Other key recommendations for the Department included in the report include:

• Working with HMS to amend data-sharing agreements with third-party insurers to require more frequent insurance updates, such as weekly updates;
• Working with the LDSS to implement new processes that would allow for more effective, efficient, and timely identification and disenrollment of individuals with comprehensive TPHI from managed care;
• Implementing controls, such as a system edit, to identify non-NYSOH-enrolled recipients with comprehensive TPHI and promptly remove them from managed care;
• Performing more frequent reviews to identify and recoup premium payments from MCOs for recipients with comprehensive TPHI beyond those payments already reported by the LDSS;
• Maintaining lists of MCO and insurer relationships to aid in the identification of managed care premium recovery opportunities, and;
• Reviewing the identified managed care premiums and recover as appropriate

The audit covered the period January 1, 2012 to September 1, 2017.

Study Published on Physician Behavior under Medical Malpractice Caps

Stat recently reported on a new study published in JAMA Cardiology that looked at how cardiac physicians’ testing and treatment decisions changed in states that have implemented medical malpractice reform.

The study found that in nine states with new malpractice damage caps, physicians ordered 24% fewer angiographies as a first test than physicians in 20 states without such caps.  Physicians in states that adopted damage caps also referred fewer patients for angiography following a stress test, and fewer patients progressed from evaluation to revascularization.  While overall testing rates did not change, the testing became less invasive (fewer initial angiographies and less progression from initial stress test to angiography).  The study’s authors contend that the findings suggest physicians are willing to tolerate greater clinical uncertainty in coronary artery disease (“CAD”) testing and treatment if they face lower malpractice risk.

Regulatory Updates

Education Department

Advanced Home Health Aides

At last week’s Board of Regents meeting, the state Education Department (“SED”) presented proposed/emergency regulations to implement the Advanced Home Health Aide (“AHHA”) legislation passed and signed in 2016.  The proposed regulations would define AHHA related terms, establish criteria for RN supervision of AHHAs, establish criteria for AHHA certification, establish criteria for AHHA training programs, and establish AHHA training and competency requirements.

These proposed/emergency regulations complement the proposed regulations that were advanced by the Department of Health in the May 30, 2018 edition of the NYS Register.

It is expected that these proposed/emergency regulations will be published in the June 27, 2018 edition of the NYS Register.  The emergency rule will become effective on June 12, 2018 and expire on September 10, 2018.

Department of Health

Update Standards for Adult Homes and Standards for Enriched Housing Programs (E)

The Department of Health recently issued a notice of emergency rulemaking that prohibit adult care facility (“ACF”) operators from excluding individuals who primarily use a wheelchair for mobility. The emergency regulations require ACF operators to make reasonable accommodations to the extent necessary to admit such individuals, consistent with the Americans with Disabilities Act (“ADA”).

These emergency regulations have been issued due to Departmental concern that some ACF operators may be denying admission solely on the grounds that applicants primarily use a wheelchair for mobility.  The Department intends to adopt this emergency regulation as a permanent regulation and will publish a notice of proposed rulemaking at a future date.

The emergency regulations are effective as of May 25, 2018, and will expire on August 22, 2018.

Managed Care Organizations

The Department of Health recently issued a notice of adopted rulemaking that reduces the contingent reserve requirements applied to premium revenues from the Medicaid Managed Care (“MMC”) and HIV Special Needs Plan (“SNP”) programs.  The reduced reserve is as follows:

• For 2016, 7.25% of net premium income (down from 8.25%)
• For 2017, 7.25% of net premium income (down from 9.25%)
• For 2018, 7.25% of net premium income (down from 10.25%)
• For 2019, 8.25% of net premium income (down from 11.25%)
• For 2020, 9.25% of net premium income (down from 12.5%)
• For 2021, 10.25% of net premium income (down from 12.5%)
• For 2022, 11.25% of net premium income
• For 2023 and beyond, 12.5% of net premium income

The adopted rulemaking also reduces the contingent reserve requirement for e Health and Recovery Plans (“HARPs”) to 5% for net premium income for years 2015, 2016, and 2017.

The regulations, as adopted, contain no changes from the proposed regulations published in the February 28, 2018 edition of the NYS Register.

Upcoming Calendar

Tuesday, June 19, 2018	New York State MRT Upstate Public Comment Day 10:30 a.m. to 4:00 p.m. Empire State Plaza, Meeting Room 6, Albany, NY
Thursday, June 21, 2018	Medicaid Managed Care Advisory Review Panel (MMCARP) 11:00 a.m. to 1:00 p.m. NYS Department of Health, Albany, NY
Monday, June 25, 2018	New York State Council on Graduate Medical Education 10:45 a.m. to 1:15 p.m. NYS Department of Health, 90 Church Street, Floor 4, Rooms A & B, New York, NY
Thursday, June 28, 2018	New York State Immunization Advisory Council 12:30 p.m. School of Public Health, Café Conference Room, 1 University Drive, Albany, NY