FIDA Reform

The New York State Department of Health (DOH) in collaboration with the Centers for Medicare and Medicaid Services (CMS) have amended the State’s Fully Integrated Duals Advantage (FIDA) program to address barriers to enrollment. As part of the FIDA reforms, specific attention was paid to improved flexibility for the participant, plans, and providers, including the changes listed below. Reforms to the FIDA program are effective immediately unless stated otherwise.

FIDA-specific provider training is no longer required, but encouraged. DOH/CMS will maintain the online training portal and continue to pursue continuing education credits for providers.

DOH/CMS will remove Sections 40.8 and 40.8.1 (Marketing Multiple Lines of Business) of the NY Marketing Guidance:

  • Plans are allowed to market multiple lines of business under the more flexible Medicare Marketing Guidelines.
  • Plans are allowed to provide a written or verbal comparison (either DOH/CMS prepared or plan-prepared) among their MLTC (Partial, PACE, MAP) and FIDA products and among their MLTC programs, and the FIDA program. 

DOH/CMS will clarify sections 70.6 and 70.9.2 of the NY Marketing Guidance which allow:

  • Plans to make outbound FIDA marketing calls to individuals enrolled in any other Medicaid or Medicare product line with the Plan/company;
  • Plans to conduct in-person marketing appointments if these appointments are solicited by the individual.
  • Plans are allowed to conduct promotional activities and make nominal gifts at the Medicare Marketing Guidelines levels ($15).
  • Plans are allowed to send, with a prior approval from DOH/CMS, FIDA educational materials (e.g., one-page letters, newsletters, etc.) to participants who have opted out.
  • DOH will send additional educational materials to Providers and conduct, with CMS, additional provider trainings with opportunities for Providers to receive educational credits.
  • Section 50.18 Disclaimer of Unsolicited Marketing Material will be removed from the NY Marketing Guidance. Plans do not have to include both the plan phone number and enrollment broker number in their marketing materials.
  • Future passive enrollment will be suspended, except in limited circumstances (e.g., when a plan is terminating and its participants are being assigned to a different FIDA plan or for the Medicare Advantage enrollees that were initially scheduled for October 1 passive enrollment whose enrollments have been postponed).
  • Enrollment in Region 2 (Suffolk and Westchester) will not start until after mid-2016.

Plans can now facilitate enrollment into FIDA:

  • Plans are permitted to submit enrollment requests to Maximus (consistent with what they do in MLTC). Maximus will process the enrollment and send letters to the individuals a) confirming their enrollment in FIDA; b) articulating that choice counseling is available through Maximus; and c) informing the Participant that s/he can change FIDA Plans or disenroll at any time. The letters will contain the ICAN contact information.
  • Plans may stay on the phone with prospective participants when they call Maximus.
  • At a minimum, the IDT will consist of a care manager and the Participant.  Participants can choose to have others (from original IDT list) participate. They are all optional members of the IDT. Their participation may vary depending on their availability, the items being discussed in a given meeting, or the needs, wishes, and goals of the Participant.
  • IDT members need not meet all at the same time.  The Care Manager may separately meet with different members of the IDT in developing the PCSP.
  • Primary care providers may choose not to participate in IDT meetings but, if willing, can review and sign off on the completed PCSP. Plans will authorize medically necessary services that are outside of the scope of practice of the IDT members involved in the PCSP development.
  • Plans will be able to develop their own procedures for communication among the IDT members, but Plans are responsible for effective and efficient information-sharing among providers even when they do not participate in the IDT, including sharing any revisions to the PCSP.

Revised Assessment Timing Requirements:

  • Plans will follow the existing MLTC schedule for the completion of Participants’ NY-UAS if the Participant comes from a sister MLTC/PACE/MAP plan. The FIDA Plan must contact the Participant and review any available medical record and claims history from the pre-enrollment period to determine whether there is a change in health status, health event, or needs that would trigger an updated NY-UAS. The new NY-UAS will be conducted within 6 months of the participant’s last NY-UAS.  PCSPs must be developed for these individuals within 90 days following their effective date of enrollment.
  • All other Participants must be assessed in a timely manner so that their PCSP can be developed and implemented within 90 days following their effective date of enrollment.

DOH/CMS will assess the performance of the FIDA Plan’s IDT delivery against existing consumer satisfaction and utilization measures.  The FIDA Plan Contract Management Team will also continue to monitor IDT operations. Specifically, the CMT will assess Plan IDT performance against the following existing measures:

  • In the last 6 months, did anyone from your health plan, doctor’s office, or clinic help coordinate your care among these doctors or other health providers? (Source: CAHPS, Item OHP3)
  • How satisfied are you with the help you received to coordinate your care in the last 12 months? (Source: CAHPS, Item OHP5)
  • Percent of Participants discharged from a hospital stay who were readmitted to a hospital within 30 days, either from the same condition as their recent hospital stay or for a different reason (Source: NCQA/HEDIS)
  • Percent of patients 65 years or older discharged from any inpatient facility and seen within 60 days following discharge by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the medical record documented. (Source: NCQA/HEDIS)
  • Percent of all Participants who saw their primary care doctor during the year (Source: HEDIS)
  • Follow-up After Hospitalization for Mental Illness (Source: NCQA/HEDIS)
  • Reporting of the number of nursing home certifiable Participants who lived outside the nursing facility (NF) during the current measurement year as a proportion of the nursing home certifiable Participants who lived outside the NF during the previous year (Source: NYSDOH)
  • Percent of Participants in the FIDA Demonstration who reside in a nursing facility, wish to return to the community, and were referred to preadmission screening teams or the Money Follows the Person Program (Source: NYSDOH).

The FIDA Plan Contract Management Team will also continue to monitor IDT operation:

  • FIDA Plans must continue to meet the Medicare-Medicaid Plan Model of Care elements and follow the existing process for updating their MOCs to reflect changes to the IDT Policy.

ADA Attestation Form: 

  • DOH/CMS hereby clarifies that:
    • No provider should be terminated from a FIDA Plan network for not answering in the affirmative to elements on the form;
    • The form is to help FIDA participants identify which providers offer specified accessibility features.
    • Completion or non-completion of the form or responding in the affirmative to elements included therein does not alter existing obligations to comply with the ADA.
    • FIDA Plans are responsible for maintaining a complete and accurate provider directory, including information collected by the ADA Attestation form. FIDA Plans have discretion on how to address any provider refusals to complete the form as they would for addressing a provider refusal to submit other directory information.

Continuity of care period: 

  • The coverage continuity period for out-of-network providers remains 90 days or until a PCSP is developed and implemented, whichever is later.

Reporting:

  • Completion of the bi-weekly and monthly dashboards is no longer required.
  • DOH/CMS will streamline several reporting measures (e.g., NY1.1, NY1.2, and NY2.1) based on the new IDT policy. Changes to these measures would be applicable beginning with the 4th quarter of 2015 (October – December) reporting period.

Quality withhold (effective upon execution of the Three-way Contract Amendments):

  • The 2015 and 2016 quality withhold payments will be tied to participation through December 31, 2016. This will essentially add a new criterion to the QW calculation that excludes an organization from receiving QW amounts if the organization does not participate at least through 2016. (QW amounts are 1% of rate in 2015 and 2% in 2016).
  • For any plans that do not continue through December 31, 2016, quality withhold amounts from 2015 and 2016 will be pooled and added to amounts earned by FIDA Plans participating on January 1, 2017 (based on 2016 performance).

CMS released HPMS Memo announcing rate updates to the Medicare A/B payments for MMPs for Contract Year 2016. CMS will provide additional information through updated CY 2016 rate letters.

CMS is conducting analysis of the Part D bids and overall reimbursement specific to plans operating in New York.  In addition, we will carefully review the Part D reconciliation experience in FIDA when we have the first year of cost reconciliation in fall 2016, as well as more recent Part D bid information as possible, and assess whether there are methodological issues that need to be addressed.

CMS is open to reconsidering the assumptions used in determining the adjustment for CY 2016 based on revised projections of enrollment and recent experience in the demonstration.