2023 Medicaid Managed Care Priorities

Dec 20, 2022 | Managed Care

The Medicaid Matters Managed Care Workgroup has published its priorities for 2023. Download the document here. These priorities are meant to accompany the coalition’s overall 2023 Health Justice Agenda.

  • Repeal Medicaid Redesign Team II Home Care Restrictions and “Lookback” enacted in 2020:
    • Repeal the restrictive minimum of three Activities of Daily Living required for eligibility for Medicaid personal care and consumer-directed services.  These ADL thresholds discriminate because applicants must now require physical assistance with three ADLs; only people with dementia will qualify based on the need for cueing and supervisory assistance with two ADLs, which is a common need for people with developmental disabilities, traumatic brain injury, visual, and many other impairments.  The new restrictions also eliminate the longstanding “Housekeeping” program, which by providing just eight hours of help per week with household chores, prevents a person with a disability from a fall or other injury that would lead to higher cost care.  
    • Repeal or improve the New York Independent Assessor.  This massive and problem-ridden bureaucracy operated by the State’s contractor, Maximus, has, since implemented in May 2022, created huge delays and obstacles to accessing Medicaid home care.  Advocates joined with managed care plans to issue a joint letter to the State on the NYIA in October 2022. 

If not repealed, protections must be enacted to mitigate some of the harm: 

  • Preserve the right of consumer to submit medical records and include their physician to be considered by all assessors and the plan or local district/county
    • Require the NYIA contractor to schedule and conduct assessments:
      • If Medicaid application is pending but not yet approved
      • When requested by any family member, attorney, care manager, or other person assisting the consumer without requiring signed authorization. 
      • Within deadlines to be specified by statute, with penalties for non-compliance. 
    • Create a public dashboard with monthly data including number of assessments conducted in person and by telehealth, number of days from the request until assessments are scheduled and conducted, ability to conduct assessments in primary language of consumer, call center hold times and language capacity, and outcomes of assessments broken down by approval or denial of Managed Long Term Care (MLTC) enrollments, mainstream service requests, and local district/county requests.  All the above should be broken down by county or region.
    • Repeal the lookback and transfer penalty for home care.  New York State has never exercised the federal option of imposing a lookback and transfer penalty for community-based care, until enacting it in 2020.  Implementation has been delayed because of protections associated with the Public Health Emergency that require states to maintain the level of access and services people currently have.  People with higher income will use trusts and other Medicaid planning techniques to circumvent these rules, but people with low income will be denied home care for transfers of moderate savings, which their family needs to spend on their behalf so they can afford to live at home.  Even those who have no assets to transfer will face huge application delays and hardship caused by the increased documentation reviews. 
  • Managed Long Term Care Transparency
    • Require public posting on New York State Open Data of financial and service data from annual Managed Medicaid Cost and Operating Reports (MMCOR) in an interactive format that enables comparison between MLTC plans and regions.  Plans file these reports with the Department of Health, but a Freedom of Information request is needed to obtain them.   The New York Legal Assistance Group MLTC Data Transparency Project (along with its associated project report) is a model for how this can be done and why it is necessary.  The MMCOR data is used for rate-setting but should also be used to hold plans accountable publicly for how billions of Medicaid dollars are spent, and for monitoring compliance with federal “rebalancing” priorities to spend more on home- and community-based services than nursing home care.  For example, if a plan is providing comparatively few hours of home care to most members, while admitting more members to nursing homes, this flags potential violations of the Olmstead decision, which provides the right to live in the most-integrated setting.
  • Require more MLTC reporting and public disclosure of data points enabling better tracking of “rebalancing” indicators and quality of care.  New York State should adopt evidence-based Managed Long Term Service & Supports (MLTSS) quality measures recommended by the federal Centers for Medicare and Medicaid Services (CMS), which focus on the use of institutional care by MLTSS health plans, adapted to track the impact of carving out nursing home care from the MLTC benefit package.[1]  Such measures include:
    • Timeliness of care and network capacity (especially in light of staffing shortages), 
    • Rate of admission of members to nursing homes, stratified by length of stay, with the percentage that successfully transition back to the community
    • Number of members “disenrolled” involuntarily from plans because of a long-term nursing home stay and for other reasons.  (Long-term nursing home care was “carved out” of the MLTC benefit in 2018, though not implemented until 2020.  No additional reporting has been required by plans to monitor whether this change is resulting in more consumers entering nursing homes and unable to return home.)
    • Number of new members who had previously been in nursing homes, with incentives to plans for enabling consumers to return home
    • Plan-specific data on appeals and grievances, including numbers and outcomes of each level of appeal, with a breakdown of the most common issues (see NYLAG MLTC Data Transparency report, supra, at 16-17, 48-49). 

All of the above measures should be disaggregated by race and ethnicity.

  • Managed Long Term Care Consumer Protections
  • Auto-Enrollment into MLTC – This would auto-assign people found eligible into MLTC plans just like what happens in mainstream managed care, if they do not select a plan on their own.  This will reduce the cherry-picking behavior by which plans avoid enrolling high-need consumers because of the higher cost of their care.
  • Automatic ex-parte Medicaid renewals for those in MLTC plans or otherwise receiving home- and community-based services – This would provide automatic recertification of those recipients on fixed incomes, for whom third-party verification would establish a high likelihood of eligibility, and for HCBS recipients, for whom suspension because of erroneous termination in the redetermination process jeopardizes health and well-being.   In vetoing the bill in 2019, the Governor claimed that CMS would not allow it and that the State would lose federal Medicaid funding.  However, CMS has recently proposed “streamlining” regulations that could pave the way to allowing this change. 

Both of these issues were addressed in one bill and we urge the Legislature to advance this legislation in 2023.  (2021-2022 bill numbers: A.155, Gottfried / S.4965, Rivera; an earlier version passed both Houses and was vetoed in 2019)

[1] See Deborah J. Lipson, Measures of State Long-Term Services and Supports System Rebalancing: HCBS Quality Measures Issue Brief, Mathematica, Nov. 2019, available at https://www.medicaid.gov/medicaid/quality-of-care/downloads/hcbs-quality-measures-brief-3-rebalancing.pdf,  p. 6-7.  See discussion in NYLAG report on MLTC Data Transparency, at https://nylag.org/wp-content/uploads/2022/09/MMCOR-Report-FINAL.3.pdf,  at pp. 43-48.