Plugged Into Health @ Hinman Straub – November 12, 2018

VBP Updates

VBP Clinical Advisory Group Webinar Slides Posted

The Department of Health has posted the Managed Long Term Care (“MLTC”) Value Based Payment (“VBP”) Clinical Advisory Group webinar slides. The webinar, which was held on September 20, provided the final MY 2019 measure set and informed the CAG about the policy for Skilled Nursing Facilities (“SNFs”). The MLTC CAG webinar slides can be found in the MLTC folder of the VBP Resource Library here.

2018 Managed Care Regional Consumer Guides Released

The Department of Health has released the 2018 Managed Care Regional Consumer Guides. The guides are available for Commercial HMO, Commercial PPO, and Medicaid and Child Health Plus, and contain a star rating for each insurer based on preventative & well-care, quality of care, and patient satisfaction. There are six regions for each product: Central, Hudson Valley, Long Island, New York City, Northeast, and Western.

To find a particular table of Consumer Guide ratings, select a Region and Payor from the dropdown lists, and click the “Produce Visualization” button.

1115 Waiver Amendment Comment Period Extended

On September 12, 2018, the Department of Health submitted to CMS a proposal to amend the New York State’s Medicaid Section 1115 Demonstration Medicaid Redesign Plan. The proposed 1115 waiver amendment seeks to implement 2018-19 Budget actions to:

1. Impose a 12-month lock-in period on enrollees of partial capitation MLTC plans (MRT 11204), and
2. Limit the partial capitation nursing home benefit for long-term stay (also called permanently placed) enrollees to three months following exhaustion of Medicare benefits (MRT 11202).

To provide stakeholders additional time to comment on the proposed amendments, the Department is accepting comments until November 23, 2018. Comments can be submitted via email to [email protected], with the subject line “Proposed NH Benefit/Lock In 1115 Amendment Comments”. Stakeholders may also submit comments directly to CMS at here.

Managed Care Policy and Planning Meeting

Last Thursday, the Department of Health held the monthly Policy and Planning Meeting with the State’s Medicaid Managed Care plans. PowerPoint presentations for topics discussed were not provided due to a new Executive review process that has now caused the presentations to not be available for the second time in three months.

Highlights from the meeting include:

• Mainstream Enrollment: Statewide enrollment for October was 4,343,000, a decrease of 21,877 or .5% since September. This continues a steady decline in MMC enrollment since July 2018.  While most of the decrease previously was attributable to enrollees migrating to HARP through passive enrollment, plans questioned if NYSOH’s policy of terminating cases upon failed address verification could be responsible for some of the recent decline.  Individuals enrolled through NYSOH who have mail returned for coverage renewal have their NYSOH cases closed.  DOH agreed to discuss with NYSOH whether this is causing the decline.
• MCO Provider Enrollment in FFS: Managed care plans continue to be advised to hold on terminating providers who have failed to enroll in FFS at this time.
• MLTC Enrollment: Overall, the MLTC program has grown by 11.3% since October 2017.  The majority of this growth continues to be in the MLTC partial cap program, which has grown by 11% over the same period.  MAP has experienced a 36% increase in enrollment.  FIDA IDD has also grown by 53% though this rate is attributable to much smaller enrollment. Enrollment in FIDA has declined by 15% since last October.
• Nursing Home Benefit Change and MLTC “Lock-in”: The Federal public comment period on the waiver amendment ended October 26. DOH is accepting additional comments thru November 23, after which it plans to submit the waiver amendment to CMS.
• LHCSA Network Limitation: As of October 25, DOH has received 91 exception requests from six MLTCs related to the contacting limitations. Half of all exceptions are related to continuity of care and half are related to geographic reasons.  DOH state that a few were for cultural or linguistic reasons.
• Community First Choice Option (CFCO): DOH officially announced that the start of CFCO for skill acquisition, maintenance, and enhancement will no longer be January 1, 2019. A new target date is still being discussed and will be shared in a forthcoming communication.

October 2018 Medicaid Update

DOH has released the October 2018 edition of its monthly Medicaid Update publication.

Some of the highlights include:

• Medicaid FFS Removing NDCs: Effective October 1, 2018, NYS Medicaid fee-for-service (“FFS”) will remove certain National Drug Codes (“NDCs”) from the formulary for which the corresponding manufacturers failed to update their Medicaid National Drug Rebate Agreement (“NDRA”), per CMS requirements. The impact of these formulary changes on Medicaid FFS members is minimal, as there is low utilization for affected NDCs and all NDCs that are being removed from the formulary have equivalent or alternative covered products. Pharmacy providers may need to utilize alternate manufacturers or in some cases, work with the prescriber to obtain a new prescription for an alternative product. Potential Labeler/Manufacturer terminations can be found here. For more information, click here.
• OMIG Issuing Controlled Substance Accumulation Letters to Pharmacy Providers and Prescribers: The Office of the Medicaid Inspector General’s (OMIG) Recipient Restriction Program has begun sending Controlled Substance Accumulation Letters to pharmacy providers and prescribers informing them when OMIG has identified a recipient who has demonstrated a pattern of obtaining excessive quantities of controlled substance medications. The educational letters serve to remind pharmacy providers and prescribers about their obligations under NYS Regulations on Controlled Substances and to specifically highlight requirements with respect to Schedule II and certain other substances. For more information, click here.
• Pharmacy Pricing Policy – Submission of Usual and Customary (U&C) Price for Pharmacy Claims: In accordance with federal regulations, pharmacies must provide a Usual and Customary (“U&C”) price when submitting pharmacy claims for prescription and over-the-counter (non-prescription) items.  The U&C price is the price charged to the general public, including applicable discounts (e.g. promotional discounts and discounted prices associated with loyalty programs) and is used to calculate the item’s Medicaid reimbursement.  For more information, click here.

ACF Cold Weather Advisory

The Department of Health (“DOH”) has recently issued Dear Administrator Letters (DAL 18-25: Cold Weather Advisory) to encourage Adult Care Facilities (“ACFs”) to take the necessary precautions to ensure that residents are comfortable and safe throughout the winter months.  The Letter includes steps that should be taken to protect residents during the cold weather months as well as advice on prevention and management of hypothermia and frostbite.

Assembly Hearing on MAT in Correctional Facilities

The NYS Assembly will hold a public hearing on Wednesday, November 14, 2018 to examine the effectiveness of medication- assisted treatment (“MAT”) programs in New York State and local correctional facilities, as well as any additional supports and services that may be utilized to serve unmet treatment needs. To view the public hearing announcement, click here.

The hearing will be held at 10:30 a.m. in the Assembly Hearing Room (19^th Floor) at 250 Broadway, New York, NY.

Persons wishing to testify should complete and return the reply form no later than Monday, November 12, 2018 at 1:00 p.m.

Regulatory Updates

Office for People with Developmental Disabilities

Telehealth

The Office for People with Developmental Disabilities (“OPWDD”) recently issued a notice of emergency/proposed rulemaking that authorizes Article 16 mental health clinics to provide access to clinical services via telehealth. The definition of “telehealth provider” was expanded in the 2018 enacted budget to include Article 16 mental health facilities and residential programs funded or operated by OPWDD.

This emergency regulation is effective October 17, 2018, and is set to expire on December 15, 2018. The OPWDD is accepting comments on the proposed rule until Thursday, December 6, 2018. Comments may be submitted by mail or electronically.

Department of Financial Services

Minimum Standards for Form, Content, and Sale of Health Insurance, Including Standards for Full and Fair Disclosure

The Department of Financial Services recently issued a notice of adopted rulemaking that authorizes accident and health insurers to issue volunteer firefighter enhanced cancer insurance policies. The rulemaking establishes minimum standards for the policies providing this insurance coverage. Among those standards, every volunteer firefighter enhanced cancer insurance policy would include lump sum benefits ranging from $25,000 to $6,250 for cancer diagnoses, a monthly benefit of $1,500 for disability caused by cancer, and a $50,000 cancer related death benefit. The minimum loss ratio (“MLR”) for volunteer firefighter enhanced cancer insurance is 75 percent.

This regulation was issued in response to Chapter 334 of the Laws of 2017 added a new General Municipal Law requiring every legally organized fire district, department or company in this state to provide eligible volunteer firefighters with enhanced cancer benefits. The benefits may either be self-funded by a fire district, department or company or be provided in an insurance policy

The adopted regulation contains no changes from the proposal that was published in the June 20, 2018 edition of the NYS Register.

Department of Health

Office-Based Surgery Practice Reports

The Department recently issued a notice of proposed rulemaking that would require office-based surgery (“OBS”) practices to report the number and types of procedures that are performed by OBS practices. Additionally, the proposal would allow the Department to request additional information as needed to interpret adverse events.  In the event the Department identifies a trend or opportunities for quality improvement through the collection of data, the proposed regulations would allow the Department to develop and implement guidelines and/or criteria for quality improvement related to the issues identified.

The Department is accepting comments on the proposed rule until December 17, 2018.  Comments may be submitted by mail or electronically.

Stroke Services

The Department recently issued a notice of proposed rulemaking that would make changes to the hospital stroke center designation program. The proposal would create a tiered voluntary stroke designation program and stroke system of care. It would allow the Department to designate a nationally recognized accrediting organization to certify the ability of hospitals to provide care to stroke patients. In addition to maintaining standards for accreditation, designated stroke centers would be required to execute written coordination agreements with one another, and would be required to have policies and procedures in place for the transfer of stroke patients to and from other hospitals. Additionally, designated stroke centers would be required to work with EMS providers to ensure that protocols are consistent with State Emergency Medical Advisory Committee, the State Emergency Medical Services Council (SEMSCO).  The Department would also be authorized to withdraw designation from a hospital for non-compliance with stroke designation criteria.

The Department is accepting comments on the proposed rule until December 17, 2018.  Comments may be submitted by mail or electronically.

Durable Medical Equipment; Medical/Surgical Supplies; Orthotic and Prosthetic Appliances; Orthopedic Footwear

The Department recently issued a notice of proposed rulemaking that would repeal regulations that limited Medicaid coverage for orthopedic footwear and compression stockings to only those recipients who had certain specified medical conditions or diagnoses.  It would also repeal regulations that limited Medicaid coverage for orthopedic footwear to only those recipients who needed them as an integral part of a lower limb orthotic appliance, as part of a diabetic treatment plan, or to address growth and development problems in children.

These regulations have been subject to litigation since they were enacted in 2011.  They are now being repealed as a result of a US District Court ruling that the benefit limitation violated the Medicaid Act’s comparability provisions.  This regulatory repeal is likely to have little to no impact, since after the district court enjoined the Department’s enforcement of these benefit limits in December 2013, Medicaid providers have been able to claim for orthopedic shoes and compression stockings pursuant to the standards in effect prior to the regulations enactment.

The Department is accepting comments on the proposed rule until December 17, 2018.  Comments may be submitted by mail or electronically.

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.

The following bill was recently signed into law by the Governor:

• 8683-A (Gottfried) / S.6882-A (Tedisco):  This bill prohibits health plans from imposing cost sharing on diagnostic testing for prostate cancer.  As a result, diagnostic testing for prostate cancer for men having a prior history of prostate cancer, men 40 and over with a family history, and men 50 and over who are asymptomatic cannot be subject to cost sharing.  This law takes effect immediately and will apply to all policies and contracts issued, renewed, modified, altered or amended on or after January 1, 2019.

Upcoming Calendar

Thursday, November 29, 2018	Public Health and Health Planning Council Committee Meetings 10:15 a.m. Empire State Plaza, Concourse Level, Meeting Room 6, Albany, NY
Thursday, November 29, 2018	DSRIP PAOP & Downstate MRT Public Comment Day 1:00 p.m. to 4:00 p.m. New York Academy of Medicine, 1216 5th Ave, Reading Room, New York, NY
Monday, December 3, 2018	Public Health and Health Planning Council, Public Health Committee Meeting 1:00 p.m. to 3:00 p.m. Department of Health, 90 Church Street, 4th Floor, Conference Rooms 4A and 4B, New York, NY