DOH: 'Care Management for All' Will Move $24b from FFS

NYAPRS Note: This new summary from the NYS Department of Health reminds us that Medicaid mental health and addiction services will move from Fee for Service (payment to providers for each visit from Medicaid) to some form of managed care coordination (payment to providers by managed care companies on a per person per month basis to cover all costs), by late 2013 or 2014.

It projects that $24 billion in current Fee for Service (FFS) Medicaid expenditures (almost half of NY’s Medicaid budget) will move to managed care over the next few years.

See http://www.health.ny.gov/health_care/medicaid/redesign/docs/2012-09-25_care_manage_for_all_transition.xls for details about this process, in the form of a draft timeline for the transition that includes three tabs; a summary, the timeline for the populations transition, and the timeline for the benefits transition. The small number of persons and benefits not transitioning is also detailed. 

 

Care Management for All

The NYS Department of Health has established a goal of having virtually all Medicaid enrollees served in care management by April 2016.  This initiative, deemed Care Management for All, began in SFY 11/12 as a Medicaid Redesign Team (MRT) proposal.  It will improve benefit coordination, quality of care, and patient outcomes over the full range of health care, including mental health, substance abuse, developmental disability, and physical health care services. 

It will also redirect almost all Medicaid spending in the state from fee-for-service Medicaid (FFS), under which service providers bill directly to the state, to care management, under which a managed care organization, of one type or another, is paid a capitated rate by the state and is then responsible for managing patient care and reimbursing service providers.  The care management system currently in place includes comprehensive plans, HIV/AIDS

special needs plans, partial capitation long term care plans, and Medicare/Medicaid supplemental plans. 

 

As Care Management for All comes to fruition, additional plans tailored to meet the needs of the transitioning population will be added, including mental health and substance abuse special needs plans, and fully integrated plans for Medicare/Medicaid “dual eligibles”.

 

As of April 1, 2012, nearly four million of the five million NYS residents enrolled in Medicaid were already in care management, with, however, a significant portion of the benefits for those persons remaining outside the care management benefit package.  Over the next four years, the bulk of the excluded benefits and patient populations will move into care management on a predetermined schedule.  For example, the non-dual eligible nursing home population is scheduled to begin moving to care management beginning in October 2013.  As another example, alcohol and drug clinic services, which are currently outside the care management benefit package, will become a care management benefit sometime in late 2013 or early 2014 when all necessary program features are in place.

 

The entire timeline for the populations and benefits transition to care management has been laid out in draft format, with a summary by state fiscal year, beginning with SFY 12/13.  The SFY 12/13 figures are based on CY 2011 data projected forward.  The dollar amounts, as well as the proposed transition dates, will likely change as the data is further refined and the implementation moves ahead.  Some of the highlights are as follows:

• Enrollment in care management will rise from 77% to 95% of the Medicaid population.

• Fee-for-service spending will ultimately drop to only 4% of all Medicaid spending.

• Of the approximately 275,000 enrollees that will remain in FFS, most are statutorily or programmatically excluded from care management due to partial eligibility rules or because they have another carrier as their primary insurer.

• When Care Management for All is fully implemented, an additional $24 billion in annual Medicaid

spending (relative to an SFY 11/12 base) will have moved from FFS to care management.

 

Questions regarding the Care Management for All initiative or the transition timeline and summary can be

directed to the NYS DOH Division of Health Plan Contracting and Oversight at arm10@health.state.ny.us.

 

http://www.health.ny.gov/health_care/medicaid/redesign/docs/care_manage_for_all.pdf