Accessing HIV Services Under Medicaid Redesign September 29, 2014 Presented by: Amy E. Lowenstein Senior Attorney Empire Justice Center © 2014 Empire Justice Center Webinar Sponsored by: The NYSDOH AIDS Institute

Agenda  Major changes to service delivery Ongoing expansion of Medicaid Managed Care New programs being created  What does this mean for people living with HIV/AIDS? Case example Advocacy strategies 2

Acronyms Abound 3 BHO – Behavioral Health Organization DISCO - Developmental Disabilities Individual Support and Care Coordination Organization FIDA – Fully Integrated Dual Advantage plan HARP – Health and Recovery Plan HH – Health Home MLTC – Managed Long Term Care MMC – Medicaid Managed Care PCP – Primary Care Provider SNP – Special Needs Plan

4 Managed Care for All: The Fundamental Driver of Change in NYS

Ongoing Expansion of Medicaid Managed Care 5 Virtually all populations and services are shifting into MMC when DOH deems appropriate Populations still in fee for service include dual eligibles, spend down & third party coverage folks, people in waivers programs (TBI, NHTD) Services still in fee for service include nursing home, mental health and substance abuse services … for now! Implementation Schedule on MRT website: _management_for_all.htm _management_for_all.htm

Special Care Management Programs 6  HIV SNPS  Health Homes (HH) Enrollees can be Fee for Service or MMC HHs absorbed targeted case management  Behavioral Health Organizations (BHOs)  Managed Long Term Care (MLTC)  Coming Soon: Fully Integrated Duals Advantage (FIDA) (1/1/15) Health and Recovery Plans (HARPs) (4/1/15) Developmental Disability Individual Support and Care Coordination Organizations (DISCOs) (10/1/15)

Health Homes 7  For those with chronic conditions in need of intensive care management  Services include engagement, tracking, plans for care, care coordination HIV COBRA case management OMH and Addiction Treatment case management  DOH or managed care plan makes assignments; counties and CBOs can make referrals  Health Homes by county: ram/medicaid_health_homes/contact_information/

Behavioral Health in MMC 8  Carve in for adult behavioral health April 1, 2015: NYC; October 1, 2015: Statewide  3 ways MMCs administer behavioral health 1.As a “qualified” plan, or 2.In contract with a BHO/experienced vendor, or 3.As a HARP – specialized MMC for people with significant behavioral health needs  MMC plan must meet certain standards: Network adequacy Evidence based assessment tools Adequate service penetration Ensure that the provider drives services

Managed Long Term Care (MLTC)  Program for dual eligible adults in need of more than 120 hours of long term care  Phased in across the state: Mandatory in half of the counties, including NYC Other counties when capacity  Consumer concerns include incentives for community based care, impartial assessments, due process rights 9

Remaining MLTC Roll-Out Schedule 10 Transition MonthCounties August 1, 2014 Dutchess, Montgomery, Broome, Fulton, Schoharie September 1, 2014Delaware, Warren October 1, 2014Niagara, Madison, Oswego November 1, 2014 Chenango, Cortland, Livingston, Ontario, Steuben, Tioga, Tompkins, Wayne December 1, 20114Genesee, Orleans, Ostego, Wyoming January 1, 2015 Chautauqua, Chemung, Seneca, Schuyler, Yates, Cattaraugus, Alleghany February 1, 2015 Essex, Clinton, Franklin, Hamilton, Jefferson, Lewis, St. Lawrence

Fully Integrated Dual Advantage  Demonstration project to coordinate care for dual eligible population  ONLY in NYC, Long Island, Westchester  FIDA provides all Medicare & Medicaid services Person-centered care model Integrated appeals process  MLTC recipients will be “passively enrolled” into a FIDA plan Passive enrollment effective April 2015 Individuals can affirmatively decline (“opt out of”) FIDA enrollment 11

12 What Changed for People Living with HIV/AIDS? Case Example

Samantha  Samantha is living with HIV, receives SSI, and is enrolled in Medicaid  How does Samantha access: Primary care? Pharmacy? Dental care? Mental health counseling? Substance use disorder treatment? Home care? 13

Primary Care under MMC  Hopefully Samantha chooses an MMC plan that includes her primary care provider (PCP) in its network 30 days to choose a plan, 90 days to switch PCP makes referrals for other services  Samantha and others with chronic conditions like HIV have the right to: Have an HIV specialist serve as their PCP, or Get standing referral to HIV specialist, and Get care at an HIV specialty center 14

Pharmacy under MMC  Each plan has its own drug formulary Formularies must be comparable (not identical) to Medicaid formulary. Link to find plan formularies:  Samantha and her doctor also need to learn her plan’s policies on: Prior authorization (all plans use standard form) Quantity limits 15

Prescriber Prevails in MMC  Samantha’s doctor has the last word on whether certain medications are medically necessary (even if non-formulary)  Prescriber prevails protections in MMC apply to 8 therapeutic classes: Anti-depressantEpilepsy Anti-retroviralEndocrine Anti-rejectionHematologic SeizureImmunologic 16

Dental Services under MMC  Medicaid’s dental benefit narrowly defined - only essential services Generally, three visits a year Primarily preventive services Tooth extractions favored over root canals Dentures replaced only every 8 years  Prior authorization required  Must use in-network providers 17

Mental Health & Substance Use Disorder Services Currently 18 SSI-related detox services Non-SSI-related inpatient mental health, outpatient mental health, inpatient rehabilitation, detox Plan Provides All other behavioral health and substance abuse services Continuing day treatment, partial day hospitalization, outpatient chemical dependency Fee for Service

Personal Care under MMC  Samantha has to go through her plan  Plan arranges for assessment and makes the authorization  Includes Consumer Directed Personal Care 19

What happens when Samantha gets Medicare?  At 65, Samantha will be Medicare eligible. Medicaid will pay her Medicare Part A & B premiums. She will get Extra Help paying for her drugs through Medicare Part D  Samantha will become a dual eligible and will be disenrolled from MMC Medicare will pay for most of her health services Medicaid will pay for services Medicare does not cover If Samantha needs more than 120 days of long term care, like home care or AIDS ADHC, she will have to join an MLTC 20

21 What if the MMC or MLTC denies or reduces services?

Advocating for Access - MMC  Transitional care for new enrollees under active treatment MMC plans must continue out-of-network care for 60 days if disabling or degenerative condition (or pregnancy).  Temporary Exemption from MMC To continue with a specialist who does not take any MMC plan. Must have an existing ongoing care plan that lasts at least 6 months Exemption ends after 6 months 22

Advocating for Access - MLTC 23  90 day transition period for new MLTC enrollees Entitled to continue long term care at the same amount and level for 90 days. Includes, personal care, adult day healthcare, private duty nursing and other long term care  No lock-in  can change MLTC

Advocating for Access MMC & MLTC  Call the DOH Managed Care Complaint Helpline:  Call the Long Term Care Ombuds Program  Coming Soon!! 24

Appeal Rights  MMC & MLTC plans have internal and external review processes Internal peer reviewers External review with State Dept. of Financial Services  Enrollees can request a fair hearing at the same time, unless Enrolled in Managed Long Term Care*  Enrollees can get aid-continuing 25

Service Limits 26  Orthotics & compression stockings – class action challenging limits (Davis v. Shah)  Occupational, Physical & Speech Therapy - 20 visits per year cap  Enteral therapy Exemption to limits expanded in 2012 to include people with HIV. Standards for enteral therapy are in regulation: opted/docs/ _coverage_of_enteral_formula.pdf opted/docs/ _coverage_of_enteral_formula.pdf

27 Questions?

For more information, contact 28 Empire Justice Center Health Technical Assistance x 5822 Amy E. Lowenstein, Senior Attorney (518) ext Also visit: