Consumer out-of-pocket spending on health care costs, including “surprise” medical bills – often incurred for costly, out-of-network care — is on the rise and state lawmakers are responding with legislation to protect consumers.
Surprise bills happen when consumers receive unexpected charges for medical care that they assumed would be comprehensively covered by their insurance plans. This often occurs when consumers unknowingly receive services from providers or facilities that are not covered within their insurance network, such as a specialist who contracts to work in a hospital, but does not participate in that hospital’s network.
Surprise bills can leave consumers on the hook for up to thousands of dollars in unexpected medical costs. This issue is pervasive throughout the health care system and affects consumers regardless of whether they are covered through individual insurance markets, such as an Affordable Care Act marketplace, or their employer. (For background on surprise billing, read NASHP’s report Answering the Thousand-Dollar Debt Question.)
Generally, state laws that address surprise billing fall into four categories:
- Laws that cap or limit charges for services that are delivered out-of-network, especially for emergency care;
- Laws designed to improve cost transparency in service costs and/or provider networks;
- Laws that set up an arbitration process to resolve surprise bills that focus on achieving a resolution between providers and insurers without burdening consumers); and
- State investments in committees to study the impact of surprise billing on state consumers.
Several states took action during the 2018 legislative session to address surprise billing, ranging from New Jersey, whose new law captures most of the above strategies, to California, New Hampshire, and New York, which passed laws to restrict “balance billing” (when providers charge patients for the difference between for what they charge and the insurer’s allowed amount.)
Below is a summary of new state laws designed to protect consumers from surprise bills.
- California AB 2593: California took aggressive action in 2017 to curb surprise billing in the state and its newest law adds to those protections by prohibiting air ambulance providers from charging consumers more than in-network costs, even if the consumer receives services from an out-of-network air ambulance provider. (It is currently awaiting governor’s signature)
- Missouri SB 982: The law requires insurers to pay providers for all emergency services “necessary to screen and stabilize an enrollee” and any additional services authorized by the insurer. Consumers cannot be held liable for cost-sharing for these services, beyond what is allowed under their insurance plans, even if the provider is out-of-network. The law also outlines a specific process for arbitration between insurers and providers to settle costs owed in cases where out-of-network care is provided to consumers.
- New Hampshire HB 1809: This law prohibits specific providers (those performing anesthesiology, radiology, emergency medicine, or pathology services) from balance billing a consumer for services in cases where the provider is out of the consumer’s network but delivers services at a hospital or ambulatory surgical center that is in the consumer’s network. New Hampshire also passed a law to establish a committee to study the balance billing practices of ambulance providers in the state. A report on the committee’s findings is due Nov. 1, 2018.
- New Jersey Chapter 32: This is of the most comprehensive surprise billing laws drafted to date. It requires:
- Health care facilities to provide clear and public information regarding the insurance plans it contracts with, the network status of providers who provide services in that facility, and the costs of services in that facility;
- Providers to share information about the insurance plans they participate in and the health care facilities they are affiliated with;
- Insurers to update and maintain accurate information about their provider networks; and
- Insurers to provide consumers with clear information regarding out-of-network health care benefits.
The law also prohibits out-of-network balance billing in the case of emergency services and sets up a process of arbitration for insurers and providers to resolve billing disputes. Notably, the law includes provisions that attempt to guarantee similar protections for consumers covered by self-insured plans, over which the state has limited authority.
- New York Chapter 57: The state’s Health and Mental Hygiene Budget includes a provision to protect survivors of sexual assault from being balance billed by a hospital, a sexual assault examiner, or a licensed health care provider.
- Oregon Chapter 43: By July 2020, Oregon’s Department of Consumer and Business Services will provide a report to the state legislature on all consumer complaints received by the state related to out-of-network providers working at in-network facilities.
Other states have actively considered bills to outlaw surprise bills and additional legislation is expected during the 2019 legislative sessions. The National Academy for State Health Policy (NASHP) will continue to monitor these bills and other efforts to address surprise billing.
On the federal level, in mid-September a group of nonpartisan US senators unveiled a draft bill that also tackles surprise billing. It adds a cap on out-of-network billing rates, prohibits surprise billing in emergency situations, and requires patients to receive notice before they receive out-of-network medical care.
Medicaid payment models in many states are shifting away from rewarding providers for the quantity of care they provide to models that reward high-quality, coordinated care that addresses some of the broader social factors that influence health and well-being. One example is New York’s Value-Based Payment (VBP) Roadmap, which rewards Medicaid providers and community-based organizations for addressing the social and economic impacts on health — such as access to healthy food, safe housing, and reliable transportation — that make up 80 percent of the factors affecting people’s health.
In New York’s model, Medicaid VBP contractors — such as accountable care organizations (ACOs), hospitals, or individual providers and their partnering networks — enter into value-based payment arrangements with Medicaid managed care organizations (MCOs). Those arrangements take one of three forms. In the Level One VBP arrangement, a traditional fee-for-service arrangement is augmented by a shared savings payment to the VBP contractor when quality scores are met. Level Two is similar to Level One, but the VBP contractor is responsible for losses if care costs more than expected and if quality targets are not met. In Level Three VBP, the MCO gives VBP contractors a set amount — a capitated or per patient, per month payment — to cover the total cost of care while meeting quality targets.
For example, a Medicaid MCO can pay a VBP contractor a flat rate or capitated payment for all the care and services required by a person with diabetes, including assistance meeting health-related social needs. VBP contractors can also develop innovations to support their VBP models. For example, one ACO in western New York partnered with a ride-sharing company to take people to urgent care or after-hours primary care as needed.
As part of the National Academy for State Health Policy’s (NASHP) accountable health models workgroup, Ryan P. Ashe, director of Medicaid Payment Reform at the New York State Department of Health, explained in a recent interview how his state’s Value-Based Payment Roadmap addresses social determinants of health.
What is your state’s value-based payment roadmap?
It is a plan to move New York Medicaid’s payment system toward a VBP model that emphasizes value instead of volume, in order to ensure the long-term sustainability of investments in clinical improvement, system transformation, population health, and community engagement, among other things. The roadmap, which charts a path toward making at least 80 percent of Medicaid managed care provider payments contracted in a VBP model, was approved in July, 2015 and updated in June 2016 and given final approval by the US Centers for Medicare & Medicaid Services (CMS) as part of the state’s Section 1115 demonstration project. The shift to value-based payment is intended to improve health and well-being of people and populations, increase the quality of clinical care, and reduce costs.
Did patients, providers, community members, and other stakeholders provide input into the roadmap’s design?
Yes. The roadmap was developed through a comprehensive and significant stakeholder engagement process. A VBP workgroup served as the advisory body guiding all major policy decisions that shape the model. The VBP workgroup was composed of providers as well as individuals from advocacy groups, community-based organizations, MC0s, and representative associations (including health plan, hospital, and physician-focused associations), among other groups. Clinical advisory groups were developed to inform clinical and behavioral health-related VBP arrangements. They also provided expertise and thought leadership, especially in relation to the design of the individual VBP arrangements such as integrated primary care and the total cost of care arrangements, for example. Subcommittees were developed to tackle specific opportunities within the VBP model. For example, a social determinants of health (SDH) subcommittee tackled a number of topics, including how the state can incentivize providers and MCOs to invest in the social factors affecting health. Comprehensive stakeholder engagement has been a cornerstone of our VBP model, and enabling a channel for public comment on the roadmap was a very important element as we moved forward. In fact, it is a practice we continue today and will continue tomorrow.
How does the roadmap motivate payers and providers to address the social determinants of health?
The VBP model requires VBP contractors — such as ACOs, hospitals, or individual providers and their partnering networks — to implement at least one intervention that addresses an SDH. The model also requires investment in interventions and rewards contractors for addressing social determinants of health, depending on the level of risk adopted in the VBP arrangement.
VBP contractors contract with MCOs under one of three arrangements:
- Level 1 is an upside-only shared savings arrangement
- Level 2 is an upside and downside risk-sharing arrangement
- Level 3 is a prospective per-member, per-month payment and/or prospective bundled payments
|“… effectively addressing social determinants of health gets to the root cause of poor health. For example, establishing stable housing helps individuals manage their medication, and access to healthy food helps address complications related to obesity or diabetes.”|
VBP contractors in Levels 2 or 3 must address at least one social determinant of health.
VBP is a mechanism to stimulate innovation and sustain transformation where it occurs. The idea is that by establishing a target goal based on overall spend and incentivizing quality, health care providers at all levels, including MCOs, will work together to provide the absolute best level of care, achieving the highest level of quality in a manner that avoids complications or emergency rooms visits that otherwise results in higher costs. In many instances, effectively addressing social determinants of health gets to the root cause of poor health. For example, establishing stable housing helps individuals manage their medication, and access to healthy food helps address complications related to obesity or diabetes. VBP creates a framework where investments in SDH interventions becomes much more important and a foundation for successful arrangements between provider partners and MCOs.
Community organizations have important insight into the needs of the communities they serve. How are they involved in implementing and guiding the roadmap?
Community based organizations are a key stakeholder in the our VBP model. It’s the community-based organizations that often have the direct line into the communities. VBP contractors in Levels 2 or 3 are required to contract with at least one community-based organization. The roadmap also recommends that MCOs and providers work with community-based organizations on interventions targeting SDH. There is a template that MCOs and community-based organizations must use when contracting with one another to implement an intervention targeting a social determinant of health. The template asks the MCO and community-based organization why they selected the intervention. For example, did they leverage an existing assessment of community needs? Or, was the decision informed by existing information sources such as the 211 service database, which tracks calls to the state’s health and human services information line? The template is a way for the state to operationalize the inclusion of CBOs in VBP arrangements. Moreover, it helps us to begin to collect information on best practices that explain why SDH interventions are being selected and how their success is being measured.
Does the state have any say over which social determinants of health that MCOs, providers, and community-based organizations address?
We want to give MCOs and community-based organizations the flexibility to design their interventions to meet the needs they see, and we want to emphasize and support opportunities to achieve the true value of the interventions. The VBP model accepts interventions that focus on five key social domains. To that end, the social determinants of health subcommittee developed a menu of evidence-based interventions that target these five key areas:
- Economic stability;
- Health and health care;
- Neighborhood environment; and
- Social, family, and community context.
The menu identifies the specific social determinants affecting each area, and lists evidence-based interventions providers can use to address them. For example, prescriptions for fruits and vegetables and nutritional counseling are possible VBP-funded interventions for food insecurity. Rental assistance, respite care, and legal services are interventions for people experiencing homelessness and housing instability. VBP contractors can pay for such interventions with savings from their Medicaid MCO payments.
Can you share any examples of how partners have used the menu of interventions to address the social determinants of health?
Yes. One provider partnered with a ride-sharing company to provide better access to medical appointments for low-income patients, because evidence shows that a lack of reliable transportation is often the main cause for missed appointments.
Another community-based organization subcontracts with some Medicaid plans to deliver medically-tailored meals to people with life-threatening illnesses. The organization says it has reduced health care costs by 28 percent compared to the costs incurred by people with similar diagnoses who did not receive medically-tailored meals, and evidence suggests such programs can improve health by reducing spending.
What is next for the roadmap?
The roadmap is a “living document,” that is updated annually and reviewed with CMS. Updates to the roadmap reflect the evolution of the model, which includes feedback from the stakeholder community. We continue to refine our arrangements and overall approach and those updates are included in the annual submission to CMS. The VBP model will continue to look at all areas of health care within Medicaid, including pharmacy, dental and transportation.
The state is committed to achieving the goal of transitioning at least 80 to 90 percent of total MCO expenditures into Level I or higher VBP arrangements. It is important to establish a framework where innovative models of care delivery can move forward, and once refined, can be sustained. This is a transformation about the way we deliver care, and also about the way we think about care, and that is where social determinants become very important. The roadmap establishes the way forward, but it also seeks to achieve a key goal — improving health outcomes for people — and that is important to remember.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
Children and youth with special health care needs (CYSHCN) are a diverse population whose health care needs and costs often exceed those of most children. Improving care for this population is critical, yet challenging, due to the complexity of conditions of some children, and the multitude of systems (e.g., health, education, social services) and supports that children typically use.
With Medicaid and CHIP programs financing health care services for 44 percent of all CYSHCN in the United States, state Medicaid agencies are increasingly targeting CYSHCN as part of their health system transformation efforts to improve health care quality and outcomes. A recent NASHP 50-state scan of state Medicaid managed care programs found that 37 states and Washington, DC, now enroll some or all populations of CYSHCN in risk-based Medicaid managed care. As state payment and delivery system reform efforts advance, tailoring quality measurement and improvement strategies to CYSHCN is a growing priority for many states to improve care for this vulnerable population.
Despite this growing interest, states face numerous barriers in implementing quality improvement strategies for CYSHCN. For example, many Medicaid agencies lack the resources and capacity to develop robust quality improvement initiatives for this population of children. Many existing quality measures have limitations in their applicability across all CYSHCN populations, and may not fully assess the overall quality of care. Surveys that can be used to measure family experience with care are often challenging and burdensome to administer. Quality improvement is a lengthy and iterative process and requires substantial time and resources for non-complex patient populations. These challenges are more pronounced when developing quality improvement initiatives that meet the unique needs of CYSHCN.
Some state Medicaid agencies, however, are leading the way by designing innovative programs and exploring new ways to align and embed quality measurement for CYSHCN in within broader state initiatives.
- Michigan: Michigan’s Children’s Special Health Care Services (CSHCS) program serves children with special needs. Michigan Medicaid utilizes the Consumer Assessment of Healthcare Providers and Systems 5.0 Child Medicaid Health Plan Survey with the Children with Chronic Conditions measurement set to assess the experience of care and quality of care for children enrolled in the CSHCS program. The survey results are used to guide improvements in the CSHCS program, and they are factored into incentive payments for the state’s managed care organizations (MCOs).
- New York: As part of New York’s overall Medicaid Redesign Team initiatives, the state is changing how children, including CYSHCN, are served in the state’s Medicaid program. One new program that is specifically driving quality measurement and improvement for CYSHCN is Health Homes Serving Children (HHSC). Through this program, participating Health Homes use a care management model to support to Medicaid-enrolled children with complex physical and/or behavioral health conditions. Health Homes report on the “Health Homes Measures Subset,” which is a list of performance measures designed to assess members’ well-being and the impact of care management activities. Some of these measures include adolescent well-care visits, time from health home referral to outreach, and follow-up after hospitalization for mental illness. The HHSC program also develops and maintains a Quality Management Program that monitors, evaluates, and ultimately improves the quality of care for members. The current quality measurement activities are laying the groundwork for New York to eventually integrate Health Homes into its statewide transition to value-based payments, with the goal of holding Health Homes accountable for the quality of care rendered and the outcomes of their members.
- Texas: Texas Medicaid serves children and youth with disabilities and complex conditions in a specialized managed care program called STAR Kids, which uses several strategies to measure and improve the quality of care for enrollees. Prior to the launch of STAR Kids, a study established baseline data for utilization, access, and consumer satisfaction. Now that the program is in its first year, Texas Medicaid will conduct a post-implementation survey of the children enrolled in STAR Kids to assess its performance, compare the performance of MCOs, and determine which measures to integrate into future quality improvement activities. Texas Medicaid also plans to implement additional quality improvement activities for STAR Kids over the next several years, including releasing MCO report cards that can help STAR Kids enrollees and their families select a health plan, and linking financial incentives and disincentives to MCO performance.
To learn more about these and other innovative Medicaid quality measurement strategies targeted to CYSHCN, read NASHP’s new issue brief, State Strategies for Medicaid Quality Improvement for Children and Youth with Special Health Care Needs. The brief includes a table highlighting selected Medicaid quality measurement sets and tools for children, and three case studies featuring ongoing work Michigan, New York, and Texas.
For more information about NASHP’s work on Medicaid Quality Measurement and CYSHCN, contact Becky Normile at email@example.com.
At NASHP’s 30th State Health Policy Conference, state leaders from legislative and executive branches across the nation gathered to talk about what they are doing to manage escalating prescription drug costs in their states. Several states have recently passed or proposed legislation to force more transparency in drug pricing or to try to regulate drug costs.
Richard N. Gottfried, a long-time proponent of drug cost regulation and member of NASHP’s Pharmacy Costs Work Group, took time at the conference to answer questions about the growing number of state legislative initiatives to rein in drug costs. Gottfried of Manhattan was first elected to the NY State Assembly in 1970, and has chaired the Assembly’s Health Committee since 1987, working to expand publicly-funded health coverage and protect patient autonomy. He also serves on NASHP’s Health Care Access and Financing Committee.
How did you get involved in drug cost regulation?
If you’re involved in health policy as I am, you cannot do this work without confronting drug prices. For many years, my own thinking has been heavily shaped by what I’ve learned meeting with people from other states who were working to control drug costs. We need to learn from each other — none of us was born understanding the pharmacy industry.
Is controlling drug prices a liberal, blue state initiative?
It’s easy to be distracted by the fact that Vermont, Oregon, and California are in the lead on some of these issues, but on the other hand, Nevada recently passed drug cost control legislation and there are proposals to control drug prices in Utah and Oklahoma.
It’s really a question of whether you are fed up with the impact of drug prices on consumers and tax payers and employers and are determined to do something about it. There may be some degree of red or blue difference in how it’s done, but certainly there are people on both sides of the aisle working aggressively on this issue. The legislation we’ve been talking about in almost every case has passed with strong bipartisan majorities.
What’s the most significant thing that has happened this year?
There is a growing understanding that state governments are not powerless here, there are things individual states can do to protect their people. This is a long-standing principle of American government, whether it’s about abolition of slavery or women’s right to vote or child labor laws, some of the most important political developments in our government began at the state level.
What do you hope will occur in the next year in terms of drug cost legislation?
I think we’ll see a lot more states sharing ideas and developing new bills to regulate drug prices and getting them enacted. I often say we state lawmakers are in one of the few lines of work where plagiarism is encouraged, and a large part of NASHP’s job is to help states learn about what other approaches states are developing and spreading that information across the country.
Should drug companies be viewed and regulated like public utilities?
I’m not sure Americans are ready to go that far, but the problem is so severe and there’s so much bad behavior in the marketplace that people are fed up and want their elected government to do something for them.
What are the obstacles state lawmakers face in implementing drug regulation?
It’s the political power of drug companies, all the articles you read about how complicated drug pricing and marketing is, the fear raised by drug company propaganda that you will be depriving people from life-saving medication, and the feeling that this is too big for a state to tackle. All of those things are more mental obstacles than real ones. Unions and consumers and hospitals and doctors and employers who pay for most of our health coverage are also pretty powerful.
What would you tell state lawmakers who want to take some action to control drug prices?
It’s complicated, but that just means you have to pay attention and learn and stick to it
New York Medicaid is directly participating in two medical home initiatives created in Chapter 58 of the Laws of 2009, the 2009-2010 state budget.
- The Adirondack Medical Home Demonstration, a five-year regional multi-payer initiative in the Northeast corner of the state.
- A statewide Patient-Centered Medical Home Program for individuals enrolled Medicaid, Family Health Plus or Child Health Plus.
Additionally, Chapter 59 of the Laws of 2011, the 2011-2012 state budget, included a section that authorizes the Commissioner of Health to establish additional multi-payer medical home initiatives similar to the Adirondack demonstration throughout the state.
Governor Cuomo’s Medicaid Redesign Team’s has also supported a recommendation (Proposal 70) to expand the statewide Patient-Centered Medical Home Program to include new payers.
- On February 3, 2012, CMS approved the first of three Section 2703 health home SPAs for “high-cost, high-need” Medicaid enrollees with chronic conditions in 10 counties. Two additional SPAs were approved in December 2012 (effective dates April 1 and July 1, 2012), expanding the program statewide. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
- The Capitol District-Hudson Valley Region of New York is one of seven markets participating in CMS’s Comprehensive Primary Care Initiative (CPCi). In this multi-payer initiative, Medicare is collaborating with public and private insurers in the selected states and regions with the goal of strengthening primary care. In New York, CPCi launched in November 2012, bringing together seven payers, as well as 74 participating primary care practices with 287 providers in the region.
- New York is one of the eight states selected to participate in the Medicare Advanced Primary Care Practice (MAPCP) demonstration program. Medicare joined the Adirondack Medical Home Demonstration as a payer in July 2011.
- New York has received a duals demonstration grant from the Centers for Medicare & Medicaid Services (CMS) to “coordinate care across primary, acute, behavioral health and long-term supports and services for dual eligible individuals.”
- HEALTHeLINK received a Beacon Community grant, creating the Western New York Beacon Community.
Last Updated: April 2014
The New York Legislature has guided current and future medical home partnerships:
In addition, Governor Cuomo tasked a multi-stakeholder Medicaid Redesign Team to reduce costs and increase quality and efficiency in the Medicaid program for the 2011-12 Fiscal Year. This team endorsed Medicaid Redesign Proposal 70, which includes the creation of a medical home advisory group to provide recommendations for the development of Health IT-derived quality, safety, and efficiency measures for pay-for-performance demonstrations.
Adirondack Medical Home Demonstration: The Adirondack Medical Home Demonstration is currently governed by a multi-stakeholder committee of payers and providers chaired by a New York State Department of Health official.
|Defining & Recognizing a Medical Home||
Adirondack Medical Home Demonstration and Statewide Patient-Centered Medical Home Program: Joint Principles of the Patient-Centered Medical Home.
New York Medicaid further describes a medical home as a physician-led care team that is responsible for providing all of a patient’s health care needs, including referrals to other physicians as necessary. Medical homes provide enhanced care that is accessible and culturally and linguistically appropriate.
Adirondack Medical Home Demonstration and Statewide Patient-Centered Medical Home Program: NCQA PPC-PCMH.
ACA Section 2703 Health Homes: Health homes are not required to achieve formal certification or recognition. They are required to meet state-developed qualification standards in five areas:
Comprehensive Primary Care Initiative (CPCi): Practices were selected for participation in CMS’s Comprehensive Primary Care Initiative through a competitive application process. Under CPCi, practices are not required to attain formal PCMH recognition; however, formal PCMH recognition through NCQA, AAHCC, the Joint Commissioner, URAC, or a state-based recognition program was viewed favorably in practice selection. Additional criteria included:
|Aligning Reimbursement & Purchasing||
Adirondack Medical Home Demonstration: Participating payers made incentive payments totaling $84 per-member per-year to support practice transformation and new care coordination services. Payment frequency was left to each payer (i.e., some paid $7 monthly, some $21 quarterly). Providers must reach NCQA PCMH Level 2 or 3 recognition within 12-18 months to continue receiving these enhanced payments.
Providers receiving Adirondack Demonstration payments are not eligible for additional payments under the Statewide Patient-Centered Medical Home Program.
Statewide Patient-Centered Medical Home Program: NCQA-recognized hospital outpatient clinics and office-based practitioners are eligible to receive enhanced service rates for certain evaluation and management (E&M) and preventative medicine codes for participating enrollees. Payments vary by NCQA level.
Hospital outpatient clinics (including FQHCs):
Medicaid discontinued payments to Level 1 NCQA PCMH providers in December 2012. The state announced in May 2013 that it would discontinue payments to practices recognized as Level 2 under the NCQA 2008 standards and reduce payment to practices recognized as Level 3 under the 2008 standards in July 2013.
Managed care plans pay a per-member per-month (PMPM) incentive payment for each participating enrollee. This payment is also tiered by NCQA recognition:
ACA Section 2703 Health Homes: Health homes receive a risk-adjusted per-member per-month care management fee that varies based on geography and case mix. Fees range from $75-$390. Health homes are paid the full PMPM rate for patients in the “active care management group” (those who are fully enrolled and have been assigned a care manager who have received at least one core health home service during the quarter), or 80% of the PMPM rate for up to six months for eligible patients in the “case finding group” (patients identified as eligible and attributed to a health home but not yet enrolled or assigned a care manager).
Comprehensive Primary Care Initiative (CPCi): This four-year multi-payer initiative, launched in November 2012, includes seven payers in New York’s Capital District-Hudson Valley market: Medicare, Aetna, Capital District Physicians’ Health Plan, Empire Blue Cross, Hudson Health Plan, MVP Health Care, and Teamsters Multi-Employer Taft Hartley Funds.
Medicare pays selected practices a per-beneficiary per-month (PBPM) risk-adjusted care management fee, which ranges from $8 to $40. CMS has indicated that it expects care management fees to average $20 PBPM during the first two years of the initiative. In Years 3 and 4, care management fees will average $15 PBPM. Medicare will also introduce a shared savings component beginning in Year 2, calculated at the market level.
The CPCi solicitation for payers indicates that participating payers (non-Medicare) are expected to follow a similar framework, paying per-member per-month (PMPM) care management fees to participating practices on top of fee-for-service and incorporating a shared savings component. Payment amounts will be negotiated individually with participating practices to comply with anti-trust laws.
Adirondack Medical Home Demonstration: Each participating Adirondack Medical Home Demonstration practices received a readiness assessment to develop individualized work plans to guide practice transformation. Practices are receiving grant-supported consulting assistance from EastPoint Health to achieve practice transformation.
Practices also receive additional support from one of three sub-regional Pods (community-based organizations providing shared care coordination services to participating practices including patient education and care management). The Adirondack Health Institute is serving as an umbrella organization for the three Pods.
A $7 million HEAL NY Phase 10 grant (HEAL NY 10) enabled all participating providers to implement an electronic health record.
It also should be noted that Chapter 59 of the Laws of 2011 authorizes the commissioner of health to provide technical assistance to regional multi-payer program participants (providers, payers and consumers), which may impact the Adirondack initiative as well as future initiatives as well.
Statewide Patient-Centered Medical Home Program: There is limited practice support from a quality organization contracted by the state.
HEAL NY 10 grants were also made available to support health IT infrastructure development for non-Adirondack medical homes.
Adirondack Medical Home Demonstration: The four major goals of the Adirondack Medical home demonstration are to:
Statewide Patient-Centered Medical Home Program: Chapter 58 of the Laws of 2009 requires the state health commissioner to report on the Statewide Patient-Centered Medical Home Program’s impact on quality, cost, and outcomes to the legislature and governor by December 31, 2012.
In addition, Chapter 59 of the Laws of 2011 requires the state health commissioner to prepare a similar annual report for the effects of regional multi-payer medical home initiatives on Medicaid, Family Health Plus, and Child Health Plus enrollees.
ACA Section 2703 Health Homes: New York will use claims and pharmacy data to measure success toward the state’s five goals for this state plan amendment:
New York is also developing a patient experience survey tool that includes elements of AHRQ’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys and implement learning collaborative with health home providers and high-risk enrollees to discuss program successes, challenges, and lessons learned.
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Many states began moving forward with their plans to expand Medicaid even before the Supreme Court’s 2012 ruling on the ACA. Other states have more recently decided to pursue expansion, with a number pursuing non-traditional Medicaid alternatives. This webinar will provide a closer look at the various ways states are expanding Medicaid to those who are newly eligible for the program. State panelists will discuss issues related to the expansion, including:
- Coordination with state or federal marketplaces;
- Education and outreach efforts for newly eligible individuals;
- Benefit design and development of the Medicaid Alternative Benefit Plan;
- Provider capacity needs for new and current enrollees; and
- Implications and opportunities for delivery system reform
Please register to join us for this lively discussion.
Alan Weil, Moderator
Executive Director, National Academy for State Health Policy
Policy Specialist, National Academy for State Health Policy
Assistant Director, Arkansas Division of Medical Services, Director of Continuity of Care and Coordination of Coverage Unit
State Medicaid Director, Deputy Commissioner, State of New York Department of Health
Deputy Director, Arizona Health Care Cost Containment System
The eight states participating in the Maximizing Enrollment program aimed to simplify and streamline enrollment and renewal policies, systems and processes for Medicaid and CHIP and prepare for ACA implementation. These state profiles offer a snapshot of the states’ work within the program by highlighting the following:
- Where states started;
- Major Simplifications Implemented as a result of Maximizing Enrollment; and
- Lessons Learned
|New York||2.1 MB|
- Most children and adults who qualify for Medicaid are enrolled into Medicaid managed care under two separate 1115 waiver programs: the New York Partnership Health Plan for individuals who belong to an income-eligible family, and a separate program for adults or children (age 0-64) who are receiving SSI payments or are otherwise disabled. Under these programs:
- Physical health services are delivered by either an managed care organization (MCO) or a primary care case management (PCCM) provider;
- Mental health and chemical dependence inpatient rehabilitation services are delivered through MCOs to all children enrolled in MCOs through the Partnership Health Plan. Historically, all SSI and SSI-related managed care enrollees have received mental health and chemical dependence inpatient services through fee-for-service, and outpatient substance abuse services provided by clinics certified by the Office of Alcohol and Substance Abuse Services have been carved out from managed care benefits under two 1115 waiver programs.
- Under the recommendations of a Medicaid Redesign Team (MRT), New York is moving to phase out the utilization of most fee-for-service Medicaid behavioral health services. In 2013, behavioral health organizations (BHOs) began risk-bearing Medicaid managed care for adults and children with serious mental illnesses or substance use disorders. New York State’s MRT goal is to have most children receive their behavioral health services through a managed care plan or BHO by April 2015.
- All MCO enrollees receive dental services from their MCO. Those not enrolled into an MCO receive these benefits on fee-for-service.
- There were a total of 4,925,236 beneficiaries enrolled in New York’s Medicaid program as of July 2011. Of these, 3,777,868 were enrolled in managed care; 3,725,644 were enrolled in a commercial or Medicaid-only MCO and 14,091 were enrolled in PCCM.
New York state law provides a definition of medical necessity:
“Medical assistance” shall mean payment of part or all of the cost of medically necessary medical, dental and remedial care, services and supplies, as authorized in this title or the regulations of the department, which are necessary to prevent, diagnose, correct or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person’s capacity for normal activity, or threaten some significant handicap and which are furnished an eligible person in accordance with this title and the regulations of the department.
The state does not have distinct statutory definitions for children, oral health services, or behavioral health services.
|Initiatives to Improve Access
In October of 2011, New York expanded Medicaid reimbursement for telemedicine services to additional care settings, and incorporated tele-psychiatry into the model. The Office of Mental Health’s (OMH) Division of Child and Family Services has established a New York Consultation and Telepsychiatry (NYCaT) program to address child psychiatric consultation needs in areas of the state with workforce shortages. The program supports mental health treatments for children in mental health programs as well as in primary care practices. To improve access to behavioral health services, New York made a policy change with CMS approval in mid-2011 allowing Medicaid reimbursement for counseling services provided by social workers. Before that change, only Federally Qualified Health Centers had been able to seek reimbursement for those services when provided by social workers.
Managed Care Incentives
|Reporting & Data Collection||
Reporting on quality of services for children
Medicaid officials in New York rely on a combination of National Committee for Quality Assurance (NCQA) Health Effectiveness Data and Information Set (HEDIS) measures and additional measures developed by the state—together known in New York as the Quality Assurance Reporting Requirements (QARR)—to monitor the quality of care provided by Medicaid MCOs. Several child-specific HEDIS measures are included in required reporting under New York’s QARR, including measures for well-child visits in the first 15 months of life, well-child visits in the 3rd, 4th, 5th, and 6th year, and adolescent well-care visits. This data is used to issue MCO-specific performance reports. The MCOs submit person-specific data on an annual basis that the Medicaid agency can use to analyze the results by race and ethnicity, location, and Medicaid coverage group. The Medicaid agency offers a managed care reference guide on encounter data submissions to provide MCOs with additional information on the process.
Collecting data for the Form CMS-416
New York requires MCOs to submit encounter data on physical health, mental health, and (where applicable) oral health to the Medicaid agency. Data elements included in encounter data include procedure codes and are listed in the “MEDS II Data Element Dictionary.” Each month Medicaid-contracted MCOs submit electronic encounter data. This data, along with claims submitted through the fee-for-service Medicaid system, is used to populate the Form CMS-416. Claims data for dental services or services provided to children who are not enrolled in managed care is submitted to eMedNY, the Medicaid program’s claims processing system. Managed care encounter data is also used to calculate risk-adjusted capitation rates, giving managed care plans a financial incentive not to underreport data.
Medicaid uses fee-for-service claims data and encounter data from MCOs to determine the number of sealants placed.
New York’s provider manual for the Child Teen Health Program was a joint Title V/Medicaid effort, and was revamped to ensure that it addressed child and adolescent emotional and behavioral health and incorporated evidence based practices.
New York Medicaid reimburses for Screening, Brief Intervention and Referral to Treatment (SBIRT) services for all Medicaid beneficiaries who are 10 years of age and older. These services are covered in hospital outpatient and emergency departments, free-standing diagnostic and treatment centers (including School-Based Health Centers), and office-based primary care practices.
New York has several home and community-based services waivers that target services to children with behavioral health conditions including:
In New York’s EPSDT/CTHP Provider Manual For Child Health Plus A (Medicaid), providers are referred to the Bright Futures in Practice: Mental Health Volume 2 Tool Kit for screening tools, including the Pediatric Symptom Checklist.
For more information about behavioral health services for children enrolled in Medicaid, see “Behavioral Health in the Medicaid Benefit for Children and Adolescents: New York.”
|Support to Providers and Families||
Support to Families
New York’s Medicaid MCO contract requires MCOs to:
Managed care contracts require MCOs to provide member handbooks and other health education through methods such as distribution of Enrollee newsletters, health education classes, or individual counseling. MCOs also typically have member portals on their websites that contain information about benefits, such as an electronic version of a Medicaid Managed Care Member Handbook.
Support to Providers
Managed care contracts require MCOs to “Educate Participating Providers about the [Child/Teen Health] program and their responsibilities under it.” The Medical Director for the Department of Health’s Office of Health Insurance Plans meets with MCO medical directors on a quarterly basis and communicates any changes in contracts or benefits to the MCOs, who can then relay the information to the provider community.
Children as well as adults are being enrolled into two medical home initiatives in New York:
The state is pursuing Health Homes authorized to receive additional federal financial participation under Section 2703 of the Affordable Care Act. Children are eligible to receive health home services; however, the state is using a priority enrollment algorithm that prioritizes non-pediatric populations. The state has also considered developing a health home program specifically for children.
The state’s Coordinated Children’s Services Initiative is a multi-agency initiative that supports county-level provision of cross-systems services to children with serious emotional disturbance (SED) who are at risk of residential placement. At the state level, participating partners include the Department of Health (which houses the Medicaid agency) and the Office of Mental Health. Every county in New York has designated a Single Point of Access to link children to Office of Mental Health (OMH) resources.
New York Medicaid’s dental delivery system relies on nearly 180 freestanding dental clinics throughout the state; over 90% of dentists in the state are practicing in private settings.
Dental services such as dental screenings and fluoride treatments are also provided to children through school-based health centers (SBHCs), including comprehensive SBHCs as well as Dental SBHCs dedicated specifically to providing dental services. Dental hygienists, dental assistants, and supervising dentists are all examples of staff that SBHCs are permitted to add to provide expanded services according to local need.