Plugged Into Health @ Hinman Straub – October 23, 2018

Executive Order 38 (“EO 38”) Decision from Court of Appeals

In a new chapter of landmark decisions regarding the administrative powers of state agencies, New York’s highest court struck down part of the EO 38 regulations which govern executive compensation and administrative expenses of organizations receiving state funding, such as Medicaid. While it upheld the “hard cap” which limits the amount of executive compensation which is directly derived from state funds, the court struck down the “soft cap” which limited the amount of executive compensation from sources other than state funds (such as Medicare and commercial payments). State agencies, including the Health Department, will need to revise the reporting requirements to reflect the more limited scope of the regulation.

Dave Luntz led a team from Hinman Straub in challenging the regulation on behalf of health care providers and health plans.

NYSOH Announces 2019 Insurance Options

The New York State of Health (“NYSOH”) has announced the Qualified Health Plan (“QHP”) and Essential Plan (“EP”) options that will be available to consumers in 2019. Open Enrollment begins November 1, 2018 and will continue through January 31, 2019.

According to the NYSOH announcement, over 95% of Marketplace enrollees will see no cost increase in 2019. This includes those who are enrolled in Medicaid and the Essential Plan and those who are eligible to enroll in a Qualified Health Plan with financial assistance.

The twelve insurers offering Qualified Health Plan coverage on the Individual Marketplace in 2019 are:

• Capital District Physicians Health Plan (“CDPHP”)
• Empire BlueCross and Empire Blue Cross Blue Shield
• Excellus (Excellus Blue Cross Blue Shield in Central NY and Univera in Western NY)
• Fidelis Care
• Health Insurance Plan of Greater New York (EmblemHealth)
• Healthfirst New York
• HealthNow New York, Inc. (BlueShield of Northeastern NY; BlueCross BlueShield of Western NY)
• Independent Health
• MetroPlus Health Plan
• MVP Health Plan, Inc.
• Oscar Insurance Corporation
• United Healthcare of New York, Inc.

The sixteen insurers offering Essential Plan coverage in 2019 are:

• Affinity Health Plan
• Capital District Physicians Health Plan (“CDPHP”)
• Crystal Run Health Plan
• Excellus (Excellus Blue Cross Blue Shield in Central NY and Univera in Western NY)
• Fidelis Care
• Health Insurance Plan of Greater New York (EmblemHealth)
• Healthfirst
• HealthNow New York, Inc. (BlueCross BlueShield of Western NY)
• HealthPlus HP (Empire BlueCross BlueShield HealthPlus)
• Independent Health
• MetroPlus Health Plan
• Molina Healthcare
• MVP Health Care
• United Healthcare
• WellCare of New York
• YourCare Health Plan

Capital District Physicians Health Plan (“CDPHP”) is the only addition to insurers offering Essential Plan coverage in 2019.

The nine insurers offering coverage on the Small Business Marketplace (“SHOP”) in 2019 are:

• Capital District Physicians Health Plan (“CDPHP”)
• Excellus (Excellus Blue Cross Blue Shield in Central NY and Univera in Western NY)
• Healthfirst
• Health Insurance Plan of Greater New York (EmblemHealth)
• Independent Health
• MetroPlus Health Plan
• MVP Health Plan, Inc.
• Oscar Insurance Corporation
• United Healthcare (Oxford)

Insurers new to the SHOP marketplace for 2019 include CDPHP, Healthfirst, EmblemHealth, Oscar, and Oxford. HealthNow offered SHOP coverage in 2018, but will not offer coverage through the SHOP marketplace in 2019.

The Marketplace will also offer the following stand-alone dental plans on the individual Marketplace:

• Delta Dental
• Dentcare
• Dentegra
• Empire BlueCross and Empire Blue Cross BlueShield
• Guardian
• HealthNow New York, Inc. (BlueShield of Northeastern NY; BlueCross BlueShield of Western NY)
• Healthplex
• Solstice

Interactive maps of the 2019 Health and Dental Plans are available at: http://info.nystateofhealth.ny.gov/PlansMap and http://info.nystateofhealth.ny.gov/EssentialPlanMap

Public Health and Health Planning Council (“PHHPC”) Meetings

On October 11, the Public Health and Health Planning Council held a full council meeting in Albany. Prior to the meeting, the Establishment and Project Review Committee (“EPRC”) met to discuss two hospital co-establishment applications that were included on the full PHHPC agenda. A copy of the full PHHPC agenda can be found here.

The Establishment and Project Review Committee (“EPRC”) failed to have sufficient votes to approve an application by The Guthrie Clinic to become the active parent/co-operator of Cortland Regional Medical Center. Although there was no recommendation for approval from the EPRC, the application was ultimately approved by the full Council by a slim margin, with Department of Health Commissioner, Howard Zucker casting the deciding vote. At the EPRC meeting, several area providers, including Cayuga Health System, Arnot Health, and the University of Rochester, testified in opposition to the application. These providers were concerned that Guthrie would steer patients away from NYS by sending them across the border into Pennsylvania, where Guthrie operates another facility.  In response to this concern, the full PHHPC required that Guthrie provide a report on patient out-migration in one year.

The EPRC also voted down a recommendation for application by Trinity Health Corporation to become a limited co-operator of St. Peter’s Health Partners. This is the first such application for “limited establishment” since the Department of Health proposed the new model at the September 17 joint meeting of the Health Planning Committee and EPRC. Unlike the majority of active parent models throughout NYS, this application would limit the powers and liabilities of the active parent (Trinity) to those related to capital debts and expenditures, leaving St. Peter’s with responsibility for managing the day-to-day operations of the facility. This being the first application of its kind, the EPRC was hesitant to set a precedent without first considering what the policy implications and unintended consequences of approval might bring. The EPRC voted to defer the application for at least one cycle so that the PHHPC could reflect and the Department of Health could come up with conditions and contingencies to attach to the application.  The full PHHPC also voted to approve the deferral.

At the full PHHPC meeting, the Council, once again, considered two related applications (True North IV DC, LLC & True North V DC, LLC) for establishment/construction of dialysis services centers. After some discussion, the Council ultimately voted to disapprove these applications. As in past meetings, the Council had concerns regarding the character and competence of the current operator, DaVita Inc., and was unable to achieve enough votes to recommend approval.

All other applications on the PHHPC agenda were approved.

The next PHHPC meeting is scheduled for Thursday, November 29, 2018 in Albany.

VBP Updates

VBP Boot Camp

DOH recently held another round of the VBP Bootcamp in Albany. The meeting included introductory remarks from Greg Allen, the Director of the Division of Policy at OHIP.  Ryan Ashe, the Director of VBP, discussed VBP principles and refreshers before turning the presentation over to DOH staff.

Denard Cummings of the Bureau of Social Determinants of Health (SDH) discussed VBP and considerations regarding Community Based Organizations and SDHs. Mr. Cummings discussed some ways for CBOs to get involved in VBP arrangements and recommended that contractors consider philanthropic sources of funding to help spur investments in SDHs. Mr. Cumming noted to date that 45 provider contracts with SDH interventions and CBOs have been approved by the Department. The VBP Roadmap requires that all Level 2 and 3 contracts implement at least one SDH intervention and include at least one Tier 1 (non-Medicaid billing) CBO. DOH reminded the audience that Form 4255 should be submitted with all VBP contracts. Contracts should be sent to the contract mailbox for mainstream MMC plans and to the MLTC Bureau for MLTC plans.

Dr. Doug Fish of DOH discussed VBP Quality Measures. While DOH requires at least one P4P  measure to be used for determining shared savings or losses, Dr. Fish noted that DOH leaves it to contracting parties to determine if a particular measure has been “met”. Dr. Fish explained that performance measures should be used for determining shared savings/losses and to adjust target budgets accordingly. He also explained that the Department is working to achieve a limited core set of outcome measures.

DOH staff from the Division of Finance & Rate Setting presented on VBP financial considerations. The presentation included a discussion about VBP penalties, stimulus funding, and efficiency and quality adjustments. One DOH staff member incorrectly noted that MMC plans have each received “$85 million in stimulus funding. Rather, in SFY 2017-18, $85 million in total funding was distributed to all MMC plans, with $60 million distributed to non-publically owned MCOs based upon engagement in Level 2 or higher contracting activity, with the remaining $25 million distributed to the remaining MCOs based on relative size.

The keynote presentation was a “payer/provider overview” titled “Stronger Together: Our Value Based Payment Experience”, which discussed a VBP partnership between MVP Health Care and Open Door Family Medical Centers and Foundation, an FQHC located in Westchester and Putnam counties that dates to 2013. Dr. Cupid Gascon, the VP of Clinical Transformation at MVP, and Dr. Daren Wu, the CMO of Open Door, were the presenters. Both individuals highlighted the importance of working in partnership to achieve common goals and praised VBP as facilitating this partnership among providers and plans. MVP discussed some of the services it provides to VBP contractors like Open Door, including a standard reporting package that includes information on ED and Inpatient utilization, gaps in care, quality measure trends, and a quarterly budget tracker. Open Doors discussed how the organization has invested heavily in EMRs and data management and analysis to get to this point. They noted that fundraising has helped cover the costs of some recent technology investments.  The entities are currently engaged in a Level 1 arrangement but anticipate soon transitioning their arrangement to a Level 2.

VBP Lessons Learned Webinar

The Department of Health will be hosting the third in the series of Early Lessons Learned Webinars from Value Based Payment (“VBP”) Pilot participants.  The webinar will take place on Wednesday, October 30, 2018, from 2:00 p.m. to 3:30 p.m.

The webinar is for Community Based Organizations (“CBOs”), Managed Long-Term Care Plans, Managed Care Organizations, and VBP Contractors, who are interested in, or are in the process of, creating and entering into a VBP contract for a social determinant of health intervention.  The webinar will feature a joint presentation from SOMOS Community Care and Northern Manhattan Improvement Corporation (“NMIC”).

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. Lana Earle was announced as the new Director of the Bureau of Long Term Care. She is currently the Deputy Director of the Division of Program Development and Management within OHIP. Highlights from the meeting include:

• Mainstream Enrollment: Statewide enrollment for September was 4,364,877, a .09% decrease from August (4,368,967) and a 2% decrease from July (4,417,638).  Enrollment decreased .26% in NYC and .14% Upstate. Most of the decrease is due to enrollees migrating to HARP through passive enrollment.
• MLTC Enrollment: MLTC enrollment through the month of September is 237,698, an increase of 2,995 since August (234,703) and 7,773 since June (229,925). Overall, the MLTC program has grown by 9.66% since last September. The majority of this growth continues to be in the MLTC partial cap program, which is currently at 215,292, an increase of 2,562 from August (212,730). All MLTC programs realized month-to-month enrollment growth with the exception of FIDA, which saw enrollment decline by 20 (3,794 vs. 3,774) with annual enrollment now down 14.32% YTD. Conversely, enrollment in MAP has increased by 30.64% since last September, with 11,832 enrollees reported compared to 11,459 one month ago.
• Nursing Home Benefit Change and MLTC “Lock-in”: CMS has completed its preliminary review of the SPA that includes a modification to the nursing home benefit in the MLTC partial cap program to limit the benefit for those enrollees who have been designated as “permanently placed” in a nursing home to three months, and that includes MLTC “lock-in”.  The SPA is now subject to the Federal public comment period that runs until October 26. In light of the fact that the lock-in was supposed to go into effect December 1 and several critical milestones remain outstanding, DOH acknowledged the actual implementation date of the lock-in will be delayed.
• FIDA: Four FIDA Plans (Agewell, GuildNet, MetroPlus, and VillageCareMax) are non-renewing for CY 2019, which will require DOH to passively enroll members into one of six remaining FIDA plans. All members moving plans will have 90 days of continuous care under their existing plan of care pursuant to continuity of care requirements. While the state expects to passively enroll most of these members into new plans, in instances where no other plans exist in the county, or the member has previously opted out of passive enrollment, members will be required to affirmatively select a new FIDA plan to remain enrolled in FIDA, or else they will return to Medicare FFS.
• Minimum Wage: Plans raised concerns with minimum wage with the Department’s minimum wage guidance during a recent webinar, where the Department indicated plans must pay “what is necessary” to meet their obligations vs. prior years where the guidance was simply to pay what is in their rates for minimum wage. DOH will likely be reaching out to plan and provider associations for further discussions.
• LHCSA Network Limitation: DOH will implement a monthly reporting process for plans to identify the LHCSAs in their network so DOH can monitor compliance with the contract limitations and track the requested exceptions.  DOH is working to streamline this as much as possible with existing provider network reporting that occurs through the PNDS (provider network data system) to alleviate administrative burden for plans.  DOH continues to work on FAQs as a follow-up to the LHCSA Contract Limitation Guidance that was issued August 20.
• Community First Choice Option (CFCO): DOH said they are actively considering a delay.  The start of CFCO for skill acquisition, maintenance, and enhancement remains January 1, 2019.  DOH is still in the process of determining CFCO rates and rate codes.  DOH recently shared draft guidance relating to Service Authorization Guidelines on Assistive Technology (AT), Environmental Modifications (E-Mods), and Vehicle Modifications (V-Mods); Person-Centered Service Planning Guidance, and Aide Training Program.

September 2018 Medicaid Update

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

Some of the highlights include:

• New Medicare Card Replacement Initiative: MBI to be Returned on Eligibility Response:  The eMedNY System is being enhanced to comply with the Centers for Medicare and Medicaid Services’ New Medicare Card Replacement Initiative. Effective September 20, 2018, the Eligibility Response for clients enrolled in both Medicare and Medicaid will return the new Medicare Beneficiary (MBI), if available, when using certain access methods for Eligibility verification. Until 12/31/2019, if the MBI is not available for the client, the HICN (“Health Insurance Claim Number”) will be returned by the access methods. After 01/01/2020, only the MBI will be returned by the access methods noted above.  For more information, click here.
• Special Income Standard for Housing Expenses:  A special income standard to help pay for housing expenses is available for certain nursing home residents and adult home residents who are on Medicaid and can safely transition to the community. Some nursing home residents and adult home residents on Medicaid may be able to be safely discharged back to the community but may not have adequate income under regular Medicaid eligibility rules to afford housing in the community. A special income standard is now available to provide an additional dollar amount of income that is added to the Medicaid income level to help individuals who qualify to pay for housing expenses in the community. The special income standard for housing expenses is available to individuals receiving Medicaid coverage of nursing facility services, other than short-term rehabilitation services, who are discharged from a nursing home to the community and enroll in, or remain enrolled in, a Medicaid Managed Long Term Care (MLTC) plan. It is also available to individuals who are in receipt of Medicaid while residing in an adult home, are discharged from an adult home to the community, and, if eligible, enroll in an MLTC plan.  For more information on this program, special income amounts, and identification of eligible individuals, click here.
• New Duplicate Editing for Pharmacy and Medical Crossover Claims:  On September 20, 2018, system enhancements were added to the eMedNY system to identify duplicate crossover claims for Medicare Part B drugs/supplies that are submitted by Pharmacies via the National Council for Prescription Drug Programs (NCPDP) and Professional format.  For more information on these edits, click here.
• New Edit to Validate Submitted Procedure Codes and Associated National Drug Codes (NDC’s):  On September 20, 2018, enhancements were added to the eMedNY system to validate submitted procedure codes and their associated NDCs. A new edit will ensure that the submitted NDC reported on a professional claim is associated with the submitted procedure code. For more information on these edits, click here.
• NYS Medicaid FFS Program Pharmacists as Immunizers Fact Sheet: NYS law and regulations permit licensed pharmacists who obtain additional certification to administer the following vaccines: Zoster, pneumococcal, meningococcal, tetanus, diphtheria, and pertussis vaccines when administered to patients 18 years of age or older; Influenza vaccines when administered to patients two years of age and older. Administration of select vaccines by qualified pharmacists employed by, or under contract with, Medicaid enrolled pharmacies is reimbursable under NYS Medicaid. For a list of conditions that apply and billing instructions, click here.

July 2018 Medicaid Global Cap Reports

The July 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 $7.715 billion, which was $31 million above the $7.684 billion target.

Medicaid spending in major Managed Care categories was $39 million over projections.  Mainstream Medicaid Managed Care was $13 million over projections through July.  Long Term Managed Care spending was $26 million over projections. Medicaid spending in major fee‐for‐service categories was $42 million (1.4%) over projections.

Health Home Update

In-person Trainings Scheduled in Preparation for the Transition to Health Home

The Department of Health has scheduled a number of upcoming in-person trainings in preparation for the transition of children into Health Homes. The training dates, locations and registration info can be viewed here. Registration is required to attend.

These State lead in-person trainings around the State are specific for current 1915c waiver providers. The in-person training is mandatory for Health Home care management (“HHCM”) staff members and supervisors. Medicaid Managed Care Plans and Lead HHs are also invited to these State in-person trainings.

The in-person trainings will be specific to the details surrounding how to transition a child to HH CM between January 1, 2019 and March 31, 2019. There will be specific in-person trainings between January and March 2019 that will be scheduled for all HH CMs and other providers specific to aspects of the children’s transition that will begin in April of 2019.

Health Home Program Chronic Condition list Update and Guidance

The Health Home program Chronic Condition list has been updated reflective of the developmental disabilities and specific guidance is provided to assist adult and children HH CMA to determine Health Home eligibility and enrollment.

Upcoming Calendar

Wednesday, October 24, 2018	NYS Board of Examiners of Nursing Home Administrators (BENHA) 10:30 a.m. to 1:00 p.m.
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, Reading Room, 1216 5th Ave, New York, NY 10029