Plugged Into Health @ Hinman Straub – August 27, 2018

VBP Updates

Physician Group Reaches New Value Based Payment Contracting Designation

The Department of Health announced that Somos Independent Practice Association has been designated as a VBP Innovator.  Somos-IPA is the first physician-led group in the State to reach VBP Innovator status.

The Somos-IPA, which is comprised of three community-based Physician IPAs: Corinthian, Excelsior, and Eastern Chinese American Physicians, will cover Bronx, Kings, Queens, and New York Counties.  The Innovator network will also partner with Montefiore Health System & St. Barnabas Hospital, MEDISYS Health System, NYU Health System, and Wycoff Heights Hospital.  The Somos-IPA Innovator network also includes seventeen community-based organizations to help address social determinants of health.  The SOMOS-IPA will care for an estimated 180,000 Medicaid members in its first year.

Earlier this year, DOH designated Montefiore ACO-IPA and NYU-Langone IPA, two hospital-led systems, as VBP Innovators.

MLTC LHSCA Contract Limitation Guidance, FAQ, & DAL Published

The Department of Health recently issued two documents providing additional information related to two new Licensed Home Care Services Agency (“LHCSA”) provisions that were implemented as part of the 2018 State budget.

MLTC LHCSA Contract Limitation

The Department of Health issued a guidance document, which has posted to the MRT 90 webpage, to Managed Long Term Care (“MLTC”) Plans on LHCSA contracting requirements.  As part of this year’s State budget, effective October 1, 2018, managed long–term care (“MLTC”) partial capitation plans must comply with a new methodology for determining the maximum number of LHCSAs with which they may contract.  The new guidance document covers MLTC enrollee notifications, provider/enrollee ratios, network adequacy, exceptions and other special situations.

LHCSA Moratorium

The Department of Health has issued a frequently asked questions (“FAQ”) document to LHCSA operators and proposed LHCSA operators with information on LHCSA certificate of need (“CON”) policy changes.  The policy changes are a result of a provision of the 2018 State budget that established a moratorium on the approval of new LHCSA licenses, and limits transfers of ownership for existing LHCSAs.  The FAQ document covers a number of topics including, among others, exceptions to the moratorium, the moratorium’s impact on ALPs, and how pending CON projects will be treated.

The Department has also issued a Dear Administrator Letter (DHCBS 18-03) to LHCSA operators to remind them of their responsibilities as the Department implements the above requirements.  The DAL does not impose any new obligations, but highlights existing LHCSA requirements related to State and Federal Anti-Kickback provisions, patient rights, privacy and choice, and previous moratorium guidance.

June 2018 Medicaid Global Cap Reports

The June 2018 Global Cap Report was recently posted on the Medicaid Redesign Team (MRT) website. The 2018 state budget extended the Global Spending Cap through March 2019. Pursuant to legislation, the Global Spending Cap has increased from $19.5 billion in FY 2017 to $20.8 billion (including the Essential Program) in FY 2018, an increase of 6.7 percent.

Total State Medicaid expenditures under the Medical Global Spending Cap for FY 2018 through June resulted in total expenditures of $6.221 billion, which was $22 million above the $6.199 billion target.

Medicaid spending in major Managed Care categories was $35 million over projections.  Mainstream Medicaid Managed Care was $12 million over projections through June.  Long Term Managed Care spending was $23 million over projections.  Medicaid spending in major fee‐for‐service categories was $33 million (1.3%) over projections.

Health Home Update

Continuity of Care and Re-engagement for Enrolled Health Home Members policy # HH0006

The Continuity of Care and Re-engagement for Enrolled Health Home Members policy # HH0006 has been revised to incorporate recent MAPP Health Home Tracking System changes and enhancements.  For further information related to the use of the new Segment Pend Reason Codes 05 and 06 and pending member segments for Diligent Search Efforts and Continued Search Efforts, please refer to the forthcoming MAPP Health Home Tracking System Release 2.6.

CMART Specifications Update (v3.6)

The Department has updated the Health Home CMART Specifications (version 3.6) to include further clarification regarding non-billable interventions.  The Department has received multiple questions regarding which mode to select when utilizing an electronic record or database to search for a member or a member’s eligibility. These actions are considered non-billable interventions as all interventions require locating a member before contacting them. Billable interventions must include care management services and the intervention mode should be the mode of communication used to contact the target of the intervention. Therefore, searching alone for a member (electronically or otherwise) is considered a non-billable intervention and should not be submitted through CMART.

Health Home Healthy Rewards and Enrollment of High Risk Members to Health Home

The Department has published final guidance on Health Home Healthy Rewards and Incentive to Enroll High Risk Members were developed based on the input of Health Homes, Managed Care Organizations, Care Management Agencies and State and Local government agency partners.

All guidance documents have been posted on the Health Homes webpage, here.

Enrollment of High Risk Members to Health Home

To accommodate Medicaid Managed Care Plans (“MMCP”), HIV/Special Need Plan(“SNP”), and Health and Recovery Plans (“HARP”) request for additional time to submit an Engagement and Enrollment (Outreach) Optimization Proposal to Enroll High Risk Members, the Department of Health will be extending the deadline to September 28, 2018.

Proposals can be submitted to the Department through the Health Home Bureau Mail Log here.  Select:  MCP/MLTC Contracts from the dropdown menu.

Regulatory Updates

Department of Health

Statewide Planning and Research Cooperative System (SPARCS)

The Department of Health recently issued a notice of proposed rulemaking that would make changes to the Statewide Planning and Research Cooperative System (“SPARCS”) submission requirements. The proposed regulation removes the requirement that SPARCS data be submitted through the Health Commerce System (“HCS”).  Instead, the regulations would allow the Department to specify the data submission system. It would also remove references to Patient Review Instrument (“PRI”) data.  These changes are intended to allow the Department to administratively select alternative data input mechanisms.  The proposed regulation would also clarify that input data dictionary elements are protected by copyright law, and therefore, the Department’s ability to publish those elements to the NYSDOH website will be limited to the extent allowed by the copyright law.

The Department will be accepting comments on the proposed regulation until Monday, October 22, 2018.  Comments may be submitted in writing or electronically.

New York State Medicaid Infertility Treatment

The Department of Health recently issued a notice of proposed rulemaking that would provide Medicaid eligible women ages 21 through 44 experiencing infertility, access to ovulation enhancing drugs, office visits, hysterosalpingogram services, pelvic ultrasounds, and blood testing.  The proposed regulation would limit covered fertility promotion drugs to bromocriptine, clomiphene citrate, letrozole and tamoxifen.  This proposed regulation implements a 2017 law that requires NYS Medicaid to cover this set of services.

The Department will be accepting comments on the proposed regulation until Monday, October 22, 2018.  Comments may be submitted in writing or electronically.

Patients’ Bill of Rights

The Department of Health recently issued a notice of proposed rulemaking that would make a number of changes to “Patients’ Bill of Rights” that must be maintained by every general hospital and provided to each patient.  The proposed regulation would prohibit discrimination based on gender identity, specify that patients have the right to identify a caregiver to be included in the discharge planning process, specify that patients have the right to view the hospital’s standard charges and a list of participating health plans, and specify that patients have the right to challenge surprise bills through the Independent Dispute Resolution (“IDR”) process.  The proposed regulation would also clarify that, in addition to the right to express their wish to donate organs, patients over the age of 16 have the right to document their consent through various mechanisms, including the NYS Donate Life Registry.

The Department will be accepting comments on the proposed regulation until Monday, October 15, 2018.  Comments may be submitted in writing or electronically.

Department of Financial Services

Establishment and Operation of Market Stabilization Mechanisms for Certain Health Insurance Markets

The Department of Financial Services recently issued a notice of adopted rulemaking that creates a supplemental risk adjustment mechanism for the small group market.  The adopted regulation is intended to provide the Superintendent with a mechanism to ameliorate potential adverse impacts of the federal risk adjustment program on carriers participating in the individual and small group health insurance markets. The adopted regulation permits the Superintendent to, in the event he/she determines that a market stabilization mechanism is necessary, implement a market stabilization pool for carriers participating in the small group health insurance market.

If the Superintendent determines that a market stabilization pool is necessary, he/she will determine the uniform percentage adjustment necessary to correct the adverse market impact.  Carriers receiving federal risk adjustment payments will be required to remit an amount equal to a uniform percentage of that payment transfer for the market stabilization pool, while carriers paying into the program will receive an amount equal to uniform percentage of that payment transfer for the applicable market stabilization pool. For the 2017 plan year, the uniform percentage will not exceed 30% of the amount to be received from the federal risk adjustment program.

The adopted regulation is substantially similar to the emergency regulations that have been in effect since June 21, 2017. However, the adopted proposal includes two additional sections that permit the application of the market stabilization mechanism on the small group health insurance market for the 2017 and 2018 plan years.

The regulation, as adopted, contains no changes from the revised proposed rulemaking that was published in the May 16, 2018 edition of the NYS Register. The Department’s assessment of public comments may be viewed here.

Legislative Spotlight

Now that the 2018 Legislative session has adjourned, bills that have passed both houses of the Legislature will be delivered to the Governor in “batches” over the next several months. Once a bill has been delivered to the Governor, he has 10 days (excluding Sundays) to either sign the bill into law or veto the bill.

No health care or insurance related bills of interest were delivered to the Governor this week.

Upcoming Calendar

Friday, September 14, 2018	New York State Department of Health Minority Health Council   9:00 a.m. to 1:00 p.m.
Thursday, September 20, 2018	Drug Utilization Review Board (DURB)   9:00 a.m. to 4:00 p.m.   Empire State Plaza, Concourse Level, Meeting Room 3, Albany, NY
Tuesday, October 9, 2018	State Health Innovation Plan Council   10:30 a.m. to 2:30 p.m.