New York State Medicare/Medicaid Integration
Program: Managed Long Term Care Plans and the
Continuing Care Network Demonstration

Project Overview

General Approach: The New York State Department of Health (DOH) has established a managed care structure, Managed Long Term Care (MLTC), to serve nursing home eligible seniors and people with disabilities. There are currently over 6,000 enrollees in New York's MLTC Plans, 96% of whom are dually eligible individuals.

The New York State Legislature enacted Chapter 659 of the Laws of 1997, the Long Term Care Integration and Finance Act (LTCIFA) which created a framework for the implementation and oversight of MLTC Plans.

The State's legislation permits integration of Medicaid and Medicare at the plan level either by demonstrating capability to achieve full capitation or the capability for benefit coordination and capitation on the Medicaid side. The State currently has four plans which are fully integrated Medicaid and Medicare capitation plans operating under the Program For All Inclusive Care for the Elderly (PACE) demonstration. However, the DOH has pursued other models of managed care for this population with the financial and technical assistance of grantors including the Commonwealth Fund and The Robert Wood Johnson Foundation. (RWJ). The Commonwealth Fund supported the development of five partial capitation plans. The RWJ grant has supported the development of the Continuing Care Network Demonstration in Monroe County. The CCN demonstration is focused on full integration of Medicaid and Medicare through Medicare waivers. However, the implementation of the CCN has proven to be complex and the financial base has taken longer to establish than was expected. RWJ is supporting projects that enable the DOH and MLTC providers to develop and operate innovative approaches to care management of the frail elderly in community settings whether the person is enrolled in a partial or full capitation plan.

Delivery System: There are several systems of long term care for dually eligible individuals in New York State. One operating model of care, under the LTCIFA, is PACE. These Federal demonstrations are capitated under Medicare and Medicaid and will be operated consistent with federal regulations and in accordance with a three-way program agreement among the provider, the Centers for Medicare and Medicaid Services (CMS) and the DOH.

The non-pace MLTC plans in New York provide Medicaid services under a partially capitated arrangement. The plans cover a full range of long term care services and coordinate access to non-covered health and social services.

The Continuing Care Demonstration (CCN) will add another dimension to existing models by offering a fully integrated program for Medicare-only and Medicare/Medicaid eligible persons in Monroe County. Unlike other New York MLTC plans, the CCN will serve the unimpaired elderly as well as those impaired in the community and in nursing homes.

Implementation Date: In New York State, there are currently four (4) operational PACE programs and ten (10) operational MLTC plans. The legislation allows for a total of 31 plans within New York. In addition, the CCN demonstration faces numerous challenges relative to solvency requirements, but continues to develop the needed infrastructure to implement the program in 2002. DOH anticipates continued growth in plan enrollment.

Waivers: In 1996, DOH's Rochester-based partner, the Community Coalition for Long Term Care (CCLTC), submitted a joint Medicare 222 and Medicaid 1115 waiver application that would permit the CCN demonstration to offer a broad spectrum of services to unimpaired and chronically ill individuals and would provide for a risk-adjusted, multi-level, capitated reimbursement system. In 1998 following discussions with HCFA on the 1115 budget neutrality requirements the DOH resubmitted the application under Medicare reimbursement authority (section 402). The application was approved in the Fall of 1999.

Although CCN was planned as a model for other plans, and the partial capitation arrangements were initially viewed as "interim" models, DOH and the plans have come to understand they offer genuine opportunities to make a difference in the delivery of both capitated and non-capitated services for this vulnerable population.

Eligible Populations:

• PACE: Participants must be at least 55 years old, live in the PACE service area, and be nursing home certifiable. Most PACE enrollees are dually eligible for Medicare and Medicaid and a small percentage are Medicare and private pay or Medicaid-only.
• MLTC Sites: Target populations are persons who are 21 and over, nursing home certifiable, living in the community upon enrollment and in need of the long term care services in the benefit package. Most plans have opted to serve the older population.
• CCN Demonstration: The target population for the CCN demonstration consists of Monroe County residents age 65 or older, entitled to Medicare or Medicare/Medicaid.

Benefit Package:

PACE: The PACE program is responsible for directly providing or arranging all primary, acute and long term care services. These include those traditionally covered by Medicare and Medicaid as well as social and environmental supports. Services covered under Medicare and Medicaid capitation include inpatient and outpatient hospital services, adult day care, ambulance, audiology, dental, dietary, occupational, physical and speech therapy, personal care, primary care and nursing facility services, and social and environmental supports. PACE uses an interdisciplinary team consisting of professionals and paraprofessionals. Adult day care centers are supplemented by in-home and referral services.

MLTC Sites: Covered services include care management, home health care, personal care, nursing home care, physical therapy, speech therapy, occupational therapy, respiratory therapy, nutrition, medical and social day care, meals, prescription/non-prescription drugs, dentistry, optometry, podiatry, audiology, transportation, medical equipment and supplies, orthotics, prosthetics, PERS, and other social and environmental supports. Physician, hospital, radiology, laboratory, mental health, substance abuse services, OMRDD services, emergency transportation, chronic renal dialysis, and family planning services are outside the benefit package, and are reimbursed on a fee-for-service basis by Medicare or Medicaid. However, the plan care managers are responsible for arranging and/or coordinating such services with the services covered by the plan.

CCN Demonstration: All enrollees will be entitled to a full range of Medicare and Medicaid primary, acute, and long term care services and will have access to care management 24 hours a day, for assessment, care planning and coordination. A chronic care benefit will include home delivered meals, personal care, social day care, PERS, Homemaker/ chore and respite services.

Quality Assurance Activities: New York's quality monitoring system has internal and external components: internal quality improvement systems that achieve demonstrable improvement in enrollee health, functional status or satisfaction across a broad spectrum of care and services; external monitoring through on-site operational and targeted reviews; data collection, reporting and analysis; and external review agent activities, the results of which are provided to plans and made available to consumers. MLTC plans have developed quality and care management techniques that have integrated Medicaid and Medicare reimbursed services on a practical level. DOH is currently facilitating work sessions to allow sharing of those techniques and quality improvement best practices across MLTC plans.

Current Status: There are four (4) PACE and ten (10) operational MLTC plans. The CCN Demonstration projects a 2002 implementation date if solvency and capitalization issues are resolved. There are currently over 6,000 enrollees in New York State MLTC plans, with continued growth anticipated.

Accomplishments:

MLTC plans have demonstrated that effective coordination among primary, acute, and long-term care providers can be accomplished if effective care management practices are established. The MLTC plans are an invaluable learning laboratory for evaluating operating standards, data management systems, and monitoring practices. Specifically, DOH has been able to accomplish the following:

• Amended existing State regulations for managed care organizations (MCOs) to accommodate MLTC as a new MCO provider type. Although these regulations have not yet been promulgated, DOH guidance consistent with the regulations has been provided to guide plans toward statutory and regulatory compliance in the interim.
• Developed a readiness review process to ensure that each plan has put in place the components necessary to successfully operate a managed care plan.
• Conducted annual onsite, operational reviews to monitor plan operations and the care management process. In-office review and analysis of required data, select policies and procedures and marketing materials support and supplement onsite reviews.
• Developed uniform data reporting requirements to foster both plan and DOH analysis of plan operations and quality of care. Plans are required to collect and make available to the DOH: utilization data; enrollment and disenrollment data; provider network records; data regarding complaints, member and provider satisfaction surveys and financial data. Plans are also required to collect data on clinical and functional characteristics of members using the DMS-1 and OASIS.
• Contracted for external quality review through Island Peer Review Organization (IPRO). IPRO has just completed the initial phase of a systems audit and data validation of MLTC plans. This phase involved development, with DOH, of a MLTC Utilization Assessment Tool that has been completed and submitted by plans. Individual plan review begins in December. In addition, two diabetes surveys (PACE and non-PACE) have been developed and the pilot program will begin in December of this year.
• Drafted and submitted to the Centers for Medicare and Medicaid Services (CMS) state and site protocol for the CCN Demonstration. A three-way protocol review process was conducted among DOH, CMS and the CCLTC through a series of conference calls.

Next Steps

• Facilitation of Care Management/Quality Improvement Work Sessions - The goal of the quarterly, DOH hosted sessions will be to help plans to articulate specific care management challenges, to develop strategies to address those challenges and to identify resources to support each strategy. Further, DOH will hold best practice sessions related to plan functions including the collection and analysis of data and use of data as a basis for quality improvement initiatives. DOH will develop technical assistance guidelines for new and operating MLTC plans.
• Data Enhancement Plan - DOH is currently developing systems to collect standardized data for a better understanding of the clinical/functional characteristics and acuity levels of persons enrolled in its plans. The data will then be used to analyze utilization patterns across plans. Analysis of OASIS data will be used to monitor quality of care and adequacy of quality initiatives.
• Diversity Outreach - New York MLTC plans provide personal, hands-on services to people in their own homes making cultural sensitivity even more important than services provided in a neutral setting. DOH will be facilitating sessions with operating plans to interpret recommended standards for culturally competent provision of services and to produce a guide to developing/adapting culturally competent resource materials and programming.
• CCN Demonstration - DOH will continue to work with the CCLTC in satisfying the terms and conditions of the Medicare waiver through the refinement of protocol and development of plan policies and procedures. The DOH will also work with CCLTC toward completion of State regulatory requirements necessary to implement the CCN Demonstration.

Contact Information

Linda Gowdy
New York State Department of Health
Director, Bureau of Continuing Care Initiatives
Office of Continuing Care
161 Delaware Avenue
Delmar, New York 12054
Phone: (518) 478-1141
Fax: (518) 478-1134
E-Mail: llg07@health.state.ny.us
Website: http://aging.state.ny.us