Understanding Medicaid Managed Long Term Care Contracting September 11, 2013 LeadingAge New York Financial Managers Annual Conference Michael H. Lewensohn Manager Health Care Medical Reimbursement Services

Discussion Topics  Definitions  Contract assessment  Facility specific costs and potential data resources  Communication  Other Issues 2

Managed Care MLTC (Managed Long Term Care) MCO (Managed Care Organization) Capitation Coordination of Care FIDA (Fully Integrated Duals Advantage) SNP (Special Needs Plan) 3 Definitions

Definitions (continued) PACE (Program of All-Inclusive Care for the Elderly) Evergreen Agreement Dual Eligible Formulary Included Services Excluded Services Capitation / Fee-For-Service 4

Rates – Multiple levels of care, based on patient needs and assessment Identify documentation requirements by level of care Included and Excluded Services – Pharmacy formulary – Rehabilitation – Medical services – Medical Diagnostic Testing (Labs, X-Ray, Supplies) Contract Assessment 5

(continued) Contract Assessment (continued) Billing Protocols – Identify billing submission period – Identify the billing appeals process Care Requirements – Delivery of care and documentation requirements – Patient assessments to support level of care/payment Credentialing of Facility Professionals – Medical staff, Rehabilitation, Testing & Supplies 6

(continued) Contract Assessment (continued) 7

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Identifying Facility Specific Costs: Potential Data Resources Medicare and Medicaid cost reports Internal facility reports Vendor historical data Available “public information” about neighboring providers Information available through trade organizations 9

Communicating MLTC Issues Staff training and ongoing communication of contractual changes Vendors Apprise vendors of when bills should be sent to the Facility versus other 3 rd party payers Patients and Families Apprise patients and or families of costs which they may be responsible to pay 10

Other Issues Facility Admission Agreement: the Facility’s contract with patients The MLTC agreement versus the Facility Admission Agreement Avoid Evergreen Contracts Request specific start and end dates of agreements Identify when re-negotiation period begins Consult legal counsel 11