The Development of Medicaid Managed Care and HIV SNPs

In recent years, many private and public sector employers have been trying to reduce the costs of providing health insurance to their employees by switching their coverage to managed care organizations. The rapid change to managed care nationwide has amounted to a virtual revolution in health care delivery and financing, and is now beginning to impact on the consignment of health services for the Medicaid population.  States, in efforts to reduce the costs of Medicaid as well as improve the coordination of health services for individuals, are terminating or curtailing their traditional fee-for-service programs and transferring the delivery of health care for the poor to the private sector through managed care organizations.

At New York State's request, the U.S. Department of Health and Human Services Health Care Financing Administration (HCFA) granted NYS a Section 1115 waiver to allow the State to phase-in mandatory enrollment of Medicaid recipients into Managed Care, also known as Managed Care Organizations (MCOs). Ambitious State enacted programs to transfer the delivery of health care for the poor to managed care organizations have confronted many challenges and difficulties, as this new health care system radically alters the way health care is delivered. Issues are even more complex for highly vulnerable populations with intensive medical needs, such as the seriously and/or terminally ill.  The introduction of market-oriented approaches to the delivery of health care services, by which managed care organizations (MCOs) naturally will try to reduce costs and improve efficiency, must be carefully balanced with the needs of those with expensive and demanding medical needs.

New York's 1115 demonstration waiver request, "The Partnership Plan", proposed to develop separate managed care plans for those with intensive medical needs, to be called the Special Needs Plans, or SNPs.  Currently the State is scheduled to implement two SNP systems – one for HIV and another for mental health (for those seriously and persistently mentally ill). State law also allows for the development of a mental health SNP for children and adolescents who are seriously and persistently mentally ill.

The HCFA Section 1115 Waiver places several stringent requirements on the State on how mandatory Medicaid Managed Care is to be phased-in throughout the State. The first half of this report shall focus on the issues that surround standard Medicaid Managed Care and the second half on the HIV SNPs.

I. Medicaid Managed Care

Counties, in coordination with the State, are responsible for administering the Medicaid Managed Care program for their residents.  However, the development and execution of the SNPs is a State responsibility.  Local social service districts must establish Medicaid Managed Care plans to be submitted to NYS Department of Health (NYS DOH) for approval. These plans must ensure that: services are available in "sufficient numbers to meet the health care needs of participants, and shall consider the extent to which major public hospitals are included within such providers' networks"; provide for the selection of managed care plans; allow public input into the development of their plans; design an enrollment process; and ensure that medical assistance recipients are fully informed of how managed care services are provided. New York City submitted its plan to NYS DOH in 1992.

The State and City's Medicaid Managed Care plan is being implemented in several stages:

• In the first stage, for those counties that enroll their Medicaid population in managed care, participants will initially have a choice of managed care or the traditional fee-for-service plan.  (Note: New York City is completing this phase.)
• In the second stage, those enrolled in Medicaid in participating counties shall be required to join a managed care plan, with some exceptions for persons with certain special needs, such as those with HIV. (Note: New York City is currently beginning this stage, and Westchester County already has implemented the mandatory enrollment of their Medicaid population into managed care.  In New York City, mandatory enrollment is being separated into five phases, each based on a particular geographic area and organized by zip code.  Each phase will be reviewed by HRSA before proceeding to the next phase.)
• In the third stage, Special Need Plans (SNPs) are developed, whereby affected populations will either have to join Medicaid Managed Care or a SNP. Before HIV-infected individuals will be required to join a managed care plan, HCFA will conduct a readiness review to ensure that even mainstream managed care plans are adequately prepared to handle HIV-positive populations, in addition to requirements imposed on the HIV SNPs. (Note: The HIV Special Needs Plan Request for Applications (RFA) has been released, but the selection of individual SNPs has not been announced and the enrollment of HIV-infected populations into these plans has not begun. The Mental Health SNP RFA was released in August 1999.)

Coverage:

Managed care programs are to provide access to "comprehensive and coordinated health care delivered in a cost effective manner," consistent with the following legislative mandates:¹

- Managed care providers must arrange for access to and enrollment of primary care practitioners and other medical service providers, which may include doctors, nurse practitioners, county health departments, hospitals, and other facilities.

- Patients must be assured access to medical services outside of the network if coverage is not reasonably available within the network or it is an emergency (including emergency services outside of the MCOs coverage area).

- Participants must have a choice of at least two managed care providers, and a choice of no less than three primary care practitioners per provider.

- A managed care provider may select a primary care practitioner (PCP) for the participant if they do not to select one on their own, taking into consideration geographic accessibility.

- Managed care providers must ensure that their networks are "adequate" to meet the needs of its participants, including ensuring that there are sufficient providers in each area of specialty practice.  NYS DOH must establish mechanisms to ensure that MCOs have sufficient capacity to meet enrollee's needs.

Enrollment Process:

In order to ensure that the recruitment and marketing by managed care organizations of Medicaid eligible participants is conducted in a properly organized and lawful fashion, NYC decided that the enrollment process, including many educational efforts, will be conducted by an independent third party. New York City and the NYS Department of Health decided that the enrollment process would be contracted out through the State to an enrollment broker, and a company named MAXIMUS was selected through a competitive bidding (RFP) process.  The Medicaid Managed Care program in New York City is known as New York Medicaid Choice.

State law mandates that the following must be provided during enrollment: a list of carve-outs not included in managed care programs, a list of managed care providers and the services each offers, a list of available practitioners, a description of the HIV and MH SNPs and their available services, and information on participants' rights. Enrollment must also be conducted in a culturally and linguistically appropriate manner. Enrollment counselors will inquire into each participants' health status to determine if any physical or behavioral conditions require immediate attention or continuity of care, and inform participants of their options under managed care.

There are important limitations on the marketing strategies that providers may use to attract participants.  The legislation strictly prohibits telephone cold-calling, door-to-door solicitations, or solicitations in emergency rooms.  New enrollees must sign an attestation that they are aware that they have a choice of providers and primary care practitioners, but that they must also exclusively use their selected primary care practitioner and plan providers. Furthermore, all marketing materials developed by an MCO or SNP must be approved by NYS DOH or the local social services district, and MCOs may not use coercive or deceptive marketing methods to encourage participants to enroll.

Participants in social service districts² that have mandatory Medicaid Managed Care have 60 days from the date notices are mailed to select a managed care provider; otherwise, one will be selected for them.   Participants may switch managed care or SNP providers or plans without cause within 90 days of first enrolling with a provider or SNP.  Participants, as per the HCFA 1115 Waiver, must be sent a notice of auto-assignment 14 days prior to the effective date of enrollment.  After the initial 90 day period, participants may be restricted to changing providers for the next nine months, except for good cause as determined by NYS DOH.  The 1115 Waiver requires that if the auto-assignment rate in any borough or county is over 40% (i.e., if under 60% of the eligible population elects to voluntarily enroll in a managed care organization), the State must investigate the reasons for this and develop a corrective action plan.

A managed care organization or SNP may not unilaterally initiate the disenrollment of a participant without prior approval of the local social service district or SDOH, and a request for disenrollment cannot be based upon a diagnosis or condition, or a participant's efforts to exercise their rights under a grievance process. A mental health SNP may disenroll a participant where clinically appropriate if the individual no longer requires the level of services provided by a MH SNP.

Coordination of Care:

As stated in the authorizing legislation, managed care providers must arrange for all relevant medical services and assist participants in selecting such services. All medically necessary services, including specialty care, must be made available and provided in a "timely" manner.  The law also states that managed care organizations must provide the full range of covered services to all participants, including early periodic screening, diagnosis and treatment services to those less than 21 years old, and comprehensive prenatal care.

Managed care providers must establish appropriate utilization and referral requirements for physicians, hospitals, and other medical services, including emergency room visits and inpatient admissions.  Specialists may be assigned as the primary care practitioner by participants requiring special care on "more than an incidental basis," and the usage of standing referrals to specialists and subspecialists for participants who require the care of such physicians on a regular basis must become part of standard procedure.

In addition, the legislation requires that managed care organizations develop systems for managing the care of the homeless and other vulnerable populations in clinically appropriate and professionally recognized ways.

Quality Assurance

NYS DOH must by law establish a comprehensive quality assurance system for managed care providers that includes performance and outcome based quality standards of care. NYS DOH must also contract with one or more quality assurance organizations (to be selected by RFP) to monitor and evaluate the quality of care and services provided by MCOs.  Information collected by the quality assurance organization(s) must be made available to the public. In addition, every MCO must have internal quality assurance systems to identify, evaluate and remedy problems relating to access, continuity and quality of care, utilization, and cost of services.

In order to determine appropriate capitation rates, NYS DOH shall contract out to an independent actuary to review and make recommendations concerning appropriate actuarial assumptions relevant to the establishment of rates.  In establishing it's recommended rates, the law requires the independent actuary to take into account the population to be served, the scope of services to be provided, the utilization of services, and the network of providers necessary to meet State standards.

There is to be a special advisory review panel on Medicaid Managed Care, consisting of 9 members appointed as follows: 3 are appointed by the Governor, 2 by the Senate, 2 by the Assembly, and one each from the minority of the Senate and Assembly.   The panel is to review the Medicaid Managed Care system with respect to a whole host of issues, from capacity, to quality of care and access, to costs.

Ineligible / Exempt Participants:

The law allows for people to exempt³ themselves from enrollment in Medicaid Managed Care under the following circumstances or medical conditions: the managed care provider is not geographically accessible to the person; pregnant women who already have an established relationship with a non-participating prenatal primary care provider; individuals who have chronic medical conditions being treated by a sub-specialist physician that is not associated with a participating managed care program; persons receiving residential alcohol or drug treatment services; mentally retarded persons receiving care; persons with developmental physical disabilities who receive home and community based services or care-at-home services under SSI; Native Americans; and those dually eligible for Medicaid and Medicare. 

Under State law the following persons are not eligible for managed care: those in long term care, a state operated psychiatric facility, or residential treatment facility for children; infants whose mother is in jail or prison; those expected to be eligible for Medicaid for less than 6 months; certifiably blind or disabled children living apart from their parents for over 30 days; nursing home residents at time of enrollment; those under hospice care at time of enrollment; those in the restricted recipient program; those who are eligible for third party health insurance and the local department of social services decides it's cost effective to support their insurance premiums; foster children under the care of a voluntary agency; and the developmentally disabled receiving day treatment or comprehensive Medicaid case management services.

Carve-Outs:

The following carve-outs are outlined in the legislation:  Day treatment services and comprehensive Medicaid case management services for the developmentally disabled; certain long term services for the mentally retarded and developmentally disabled; TB directly administered therapy; AIDS adult day health care; HIV COBRA case management; and other services as determined by the State Commissioner of Health.

II. HIV Special Needs Plans (SNPs)

The HIV Special Needs Plans, or SNPs, are uniquely designed managed care plans specifically for persons with HIV who receive their health care through the Medicaid financing system.  The SNPs will operate in ways that are very similar to traditional Medicaid managed care plans, but shall incorporate additional services that are designed to meet the needs of persons living with HIV and AIDS.  As per state law, the NYS Department of Health is responsible for developing the Medicaid financed SNP program. Individual organizations (profit and not-for-profit) are then offered the opportunity to compete to become licensed as a designated SNP program, just as individual MCOs have been licensed by NYS to enroll standard Medicaid recipients.  State law allows for the approval of up to twelve SNPs throughout New York State. 

Enrollment

Individuals qualified for HIV SNP enrollment will be those who are HIV positive, regardless of health, as well as the uninfected children (up to age 19) of parents/guardians who are HIV positive.  Uninfected spouses/partners are not mentioned and are assumed to not be eligible for coverage.

Persons who are eligible for Medicaid, SSI or meet certain income criteria, who can demonstrate their HIV status, may voluntarily enroll in an HIV SNP.  HIV infected individuals who are Medicaid eligible are permitted to terminate or change MCOs and to change HIV SNPs without cause at any time. Change in enrollment status must take place within 45 days of requesting such a change (the details are slightly more complicated).

The enrollment process is similar to Medicaid Managed Care in that recipients are entitled to select among SNPs contracted with the State to provide such services, and are also entitled to select their own primary care physician (PCP) among those included in the SNP's network. SNPs must comply with restrictions on marketing practices that are similar to those required of mainstream MCOs (see p. 3).

An HIV SNP may only disenroll a member without their approval if they regularly fail to maintain scheduled appointments, continually use emergency rooms for non-emergency conditions, refuse medically necessary treatment, or are verbally abusive to SNP employees/providers (assuming behavior is not due to a medical condition), with the approval of the LDSS (NYS DOH approval is required in New York City).

Financing:

Services will be funded through a monthly capitation rate. The capitation rate, at least for the first year, is provided at 95% of what the fee-for-service maximum reimbursement rates are for a typical person living with HIV. Payment per SNP enrollee also varies by the following four factors: age (under or over 21 years old), geographic region (NYC, downstate metro, and rest of state), disease stage (HIV or AIDS diagnosis), and eligibility category (ADC/HR or SSI). Capitation payments will also vary depending on whether individual HIV SNPs choose to include dental care and/or transportation, and may be impacted by the introduction of mental health SNPs down the road.  HIVHIVIn addition to the capitation rate, stop-loss, fee-for-service (carve-outs) and grant-funded benefits also exist, which are explained later.

Timeline:

The following is a short-term and long-term timeline for the HIV SNPs:

Timeline in the RFA:

RFA Released:  May 3, 1999

Letter of Intent from HIV SNP applicants:  May 28, 1999

Offerer's Conferences: July 8 & 9, 1999

Applications due:  October 1, 1999

Notice of application qualification: January 3, 2000

Readiness Reviews: March 2000

Certificate of Authority Issued: May 10, 2000

Enrollment in an HIV SNP will occur in two phases: in the first stage recipients will have the option of voluntary enrolling in an HIV SNP, joining a mainstream MCO or remaining in the fee-for-service delivery system. Enrollment in an HIV SNP on a voluntary basis may begin once the State has qualified the HIV SNPs, but HCFA has not yet approved them for mandatory enrollment.  At the completion of this phase, the State must submit a report to HCFA that provides an analysis of the quality of care and level of client satisfaction of the State's voluntary SNP program. Currently, the State has released the criteria for HIV SNP application (the RFA), and the State will begin reviewing HIV SNPs applications in response to the RFA starting in September 1999.  It is anticipated that the voluntary enrollment of HIV-infected persons into the HIV SNPs will begin in July 2000.

In addition, HCFA in the 1115 Waiver created a "milestone" process whereby the State must meet a series of conditions before proceeding to phase two.  Milestone tasks for establishing HIV SNPs include: development of RFP for procurement of SNPs, establishment of benefit package, development of ratesetting methodology, finalization of capitation rates, creation of stop-loss re-insurance program, development of an MIS system, development of education and outreach materials, development of criteria for enrollment/disenrollment, development of criteria to evaluate provider capacity, approval of provider networks by HCFA, creation of written plan for monitoring quality of care and performance, conduct review of SNPs within 3 months of initial enrollment and develop special complaint, grievance and appeal process.  Most of the milestone tasks have been completed by the State with the release of the RFA.

In the second phase, whereby the State has completed a readiness review process and HCFA has certified that the Milestone process has been completed satisfactorily, HIV-infected Medicaid recipients will be required to either enroll in a mainstream MCO or an HIV SNP.  The fee-for-service delivery system for the HIV-infected will no longer be an available option after this juncture.

NYS Law Mandates

Chapter 649 of the 1996 Laws of New York granted the NYS DOH the authority to create specialty managed care plans for those with HIV and mental illness.  In addition to the State legislation, the HCFA Section 1115 waiver also lists conditions that the State must fulfill, although most of the requirements of the 1115 waiver have been incorporated into State law. The main tenements of the State law are:

1) HIV SNPs shall be responsible for providing or arranging for all medical assistance services, including: early and periodic screening, adolescent health, diagnosis and treatment and child/teen health services, prenatal care; referrals for other necessary services, linkages to HIV counseling and testing and HIV prevention and education activities. The SNPs are also responsible for managing the care of participants through case managers, ensuring coordination of care, and providing referrals where appropriate, including access to specialty services outside of the network if unavailable in the network. Standing referrals to specialists must also be permitted if such care is medically required on a regular basis.

2) In order for a plan to become a certified HIV SNP, it must: have a network of providers and facilities that provide HIV specialty services; be financially sound; assure the provision of services in a "timely" manner and have adequate personnel and facilities; have outreach mechanisms for the HIV population, including the homeless, those with substance abuse problems, and other vulnerable populations; it must have linguistically and culturally appropriate communication mechanisms; have mechanisms to monitor the quality of care that meets the AIDS Institute's established clinical standards; and have established grievance procedures.

3) NYS DOH shall review and approve all contracts/agreements with network members, including any risk sharing arrangements.

4) SNPs must also have contractual arrangements with community-based social service agencies to ensure access to a "full continuum of services needed by HIV infected persons."

5) Participants have the right to disenroll from an HIV SNP or change providers, and the social services district must process such requests in a "timely" manner.

6) DOH must establish a stop loss reinsurance program to ensure the financial viability of the SNPs in order to provide protection for catastrophic cases and adverse selection.

7) DOH must establish a quality assurance program that reflects clinical standards of care established by the AIDS Institute.

8) The legislation places a cap of 12 HIV SNPs, 6 adult mental health SNPs, and 3 children/adolescent mental health SNPs statewide.

Throughout the two phases, HCFA through the Section 1115 Waiver has a tremendous amount of oversight and program monitoring powers it may elect to exercise.  The State is required at a variety of stages to generate reports to be submitted to HCFA that outline how the HIV SNPs and mainstream MCOs are prepared to address the needs of HIV-infected clients.

Qualified HIV Providers

In order to qualify as an HIV specialist the AIDS Institute is requiring that the primary care specialist must either have experience in the clinical management of persons with HIV as part of an on-going residency program, fellowship, private practice, or clinical or hospital based practice during the past two years, or have hands-on experience over the past two years in an HIV-specific mini-residency program provided by a teaching institution or sponsored by a Designated AIDS Center or through an AIDS Education and Training Center. No training or certification in a specific medical specialty is required to be an HIV specialist. Nurse practitioners and physician assistants providing clinical care to HIV-infected individuals under a physician's supervision may also be primary care physicians (PCP) if they meet the HIV specialist criteria.

In addition, to qualify as an HIV specialist and be designated as a PCP, a provider must practice at least sixteen (16) hours per week at his/her primary care sites(s) and must make referrals for specialty care and other medically necessary services, coordinate each patient's overall course of care and maintain a current medical record for each member.  The RFA lists some exemptions to the above regulations.

Service Package

As licensed MCOs under State health law, all the HIV SNPs shall be required to meet the regulations for a basic service package mandated for all MCOs. The enacting legislation does have a separate section for the HIV SNPs, however, that includes additional requirements.  Covered services must be available to all members within 30 miles or 30 minutes travel time from the residence of the member, except in rural areas.  All members must have access to health coverage 24 hours a day, 7 days a week.  Linkages with family-centered clinical and social support services must be incorporated into the SNP networks, along with mental health, alcohol and substance abuse services.  Network coverage must include services for women and adolescents. One-stop shopping models are encouraged. Like all Medicaid MCOs in NYS, the cultural and linguistic needs of the SNP members must be taken into consideration when establishing networks with providers and CBOs.

Furthermore, members are not required to seek pre-approval for medical or behavioral health emergencies, as judged by a "prudent layperson" as an emergency, and they may seek such emergency services out of network without penalty.

Basic Benefit Package:

The RFA lists a host of minimum services that all HIV SNPs shall be required to provide that are financed through the single capitated rate mechanism.  All of these services must be made available within the SNP network and must meet basic access standards as stated earlier. They include:

• counseling and testing,
• inpatient/outpatient hospital care,
• physician services,
• acute home health services,
• emergency room,
• primary/secondary prevention,
• foot care,
• medical equipment,
• radiology,
• diagnostic services,
• dental services (optional),
• prosthetic/orthotic services,
• physical/occupational/speech therapy,
• laboratory costs,
• hearing aids,
• family planning/reproductive services,
• nursing services,
• ambulatory care,
• organ transplants,
• eye/low vision care,
• screenings,
• transportation (optional depending on local social service district policies),*
• mental health and substance abuse (with stop-loss),
• inpatient detoxification (with stop-loss),
• certain case management services, and
• any court order benefits.

* In New York City emergent and non-emergent transportation services are covered in the benefit package.

Stop-loss benefits:

Certain mental health, alcoholism, and substance abuse services have a limit on the financial liability of the HIV SNPs. Once the limit is exceed, the HIV SNPs will still be required to continue to provide these services, but they will be directly compensated for the costs of these services through the State Medicaid program.

In addition, HIV SNPs will only be totally liable for the first $100,000 of per client costs for in-patient services. The State will reimburse HIV SNPs for 85% of in-patient costs that amount to between $100,000 and $300,000 per client.  Amounts over $300,000 per client are fully reimbursed by the State.

Fee-for-Service Benefits:

The following services shall be reimbursed by the State on a fee for service basis.  However, the HIV SNPs shall still be required to assure that enrollees have access to these services on an ongoing basis. Patients will not be required to use network providers; any Medicaid provider can be used. However, HIV SNPs will still be required to have arrangements with providers that offer these services and ensure that SNP enrollees have access to these services.  They are:

• prescription/non-prescription drugs and certain medical and surgical supplies,
• methadone maintenance treatment,
• substance abuse services provided by 1035 facilities (medically supervised services),
• outpatient alcoholism rehab services,
• intensive psychiatric rehabilitation treatment programs,
• certain mental health services (day treatment, intensive case management, and partial hospitalization),
• rehabilitation services provided to residents of OMH community residences and family based treatment programs,
• mental retardation services,
• personal care agency services,
• early intervention program,
• welfare reform related alcohol and substance abuse services,
• COBRA,
• AIDS adult day health care,
• TB directly observed therapy,
• day treatment and case management for persons with developmental disabilities,
• school based health center services, and
• hospice care

Fee-for-Service or Network Covered Benefits:

Each HIV SNP has the option of including dental care, an in some LDSS's (but not NYC) the SNP may have the option to include or exclude transportation services. If they choose not to include these items in their network, they will receive a reduction in their capitation rate for each of these services.  Further information on the dental coverage program is available on page 13.

Linkage Agreements:

In addition to the mandated services that must be made available through the standard capitated rate mechanism, the HIV SNPs are required to have linkage agreements with additional providers to facilitate enrollees' access to health and psycho-social services that "support members' ability to sustain wellness and to adhere to treatment regimens."  The RFA includes a list of provider types that the SNPs should, as appropriate, have agreements with.  In addition to linkages, the SNPs are also responsible for insuring that enrollees actually receive services through these organizations.

Some of the service providers that the RFA lists (but linkages are not limited to these organizations and not all are listed below) are:

• Ryan White CARE Act and other grant-funded social service providers;
• CBOs offering HIV case management services;
• School-based health clinics;
• Providers offering HIV prevention and risk reduction, early intervention, counseling, and treatment education to support and promote adherence;
• Providers offering substance abuse treatment readiness assessment, counseling and referrals;
• Harm reduction and needle-exchange providers;
• Providers offering mental health assessments
• Programs offering counseling and assistance with partner notification;
• Permanency planning and transitional service providers;
• STD specialty clinics;
• Providers of services for the homeless, victims of domestic abuse and shelters; and
• Migrant health centers

Network Providers (Qualifications and Coverage):

All network physicians must be board certified or board-eligible in their area of specialty and/or have completed an accredited residency program.  All network primary care physicians (PCPs) must be HIV specialists as defined by the NYSDOH AIDS Institute.

All HIV SNPs must include as part of their network health providers of the following nature:

• Community health providers experienced in HIV care;
• Providers offering co-located HIV primary care and substance abuse services;
• Providers experienced in offering HIV care to HIV-infected pregnant women, HIV exposed newborns, HIV-infected children, adolescents, and young adults, and families affected by HIV; and
• Providers offering co-located HIV primary care and mental health services.

Mental Health and Substance Abuse Treatment Services:

SNPs are responsible for evaluating the mental health and substance abuse status of each of their clients upon enrollment. Each of the SNPs shall be responsible for establishing their own screening instrument to evaluate the mental health and substance abuse treatment needs of their participants.  Persons in need of these services are then to be referred to the proper treatment services.

HIV SNPs must include mental health and substance abuse providers in their network "sufficient to meet the anticipated needs for these services by HIV SNP enrollees."  The SNPs shall be required to target high-risk populations, utilize screening tools (formal assessment instruments must be used to screen patients) and coordinate PCP services with mental health and substance abuse treatment services. 

Programs may include individual practices, programs and/or clinics that are licensed by the NYS Office of Mental Health and the Office of Alcohol and Substance Abuse Services.  The HIV SNPs are strongly encouraged to include OMH and OASAS licensed programs. Individual mental health and substance abuse providers are defined as: psychiatrists, psychologists, psychiatric nurse practitioners, psychiatric clinic nurse specialists, licensed certified social workers, or certified drug and alcohol counselors.

The benefit package must include coverage for 20 outpatient mental health visits, 60 days of outpatient alcohol and substance abuse services, and 30 days combined mental health/substance abuse inpatient treatment. Mental Health day treatment and continuing day treatment, intensive case management, and partial hospitalization are all carve outs that will remain fee-for-service benefits.  Methadone maintenance treatment, substance abuse services in 1035 facilities, and outpatient alcoholism rehabilitation services will also remain fee-for-service funded programs.

In addition, persons enrolled in an HIV SNP are also eligible to dually enroll in a Mental Health Special Needs Plan, once they are developed and operational. The HIV SNP, however, remains responsible for overall care coordination, making referrals and assuring access to treatment.  If an individual who is enrolled in an HIV SNP exhausts their HIV SNP's covered mental health benefits, they may either continue to receive services under a stop-loss arrangement or may choose to co-enroll in a MH SNP.

Reproductive Health

In compliance with Federal Medicaid law, all HIV SNPs must allow enrollees to access any qualified Medicaid provider that provides reproductive and family planning services, regardless of whether such provider is a member of the SNP's network.  No referral from the PCP or the HIV SNP is required to access reproductive health services, and the HIV SNP is required to pay all Medicaid approved fees for such services.

Dental Care

HIV SNPs will not be required to include dental care in their basic package of services. However, if they do not include dental care in their basic package, their capitation payment will be reduced. Those SNPs that elect to include dental care in their network must establish a network of oral care providers in sufficient number and proximity to enrollees such that each enrollee has a choice of at least two dentists, one pediatric dentist and one oral surgeon within their service area. HIV SNPs that chose not to include dental care as part of their capitated rate will still be required to establish "formal referral arrangements" with dental care providers that accept Medicaid. The SNPs are "encouraged" to include dentists with expertise in serving persons with HIV infection, but are not required to do so.

Case Management

The RFA identifies several different models of case management that must be available to all HIV SNP enrollees. They are:

• Clinical coordination and medical case management
• Utilization management
• Assessment and service plan development that address identified patient needs
• Case manager involvement in quality assurance and continuous quality improvement (CQI)
• Non-intensive psychosocial case management
• Intensive COBRA case management (fee-for-service). HIV SNPs may apply for COBRA certification after acquiring two years of HIV case management experience.

SNP case management activities include: clinical care coordination, assessment of the need for non-intensive and intensive psychosocial case management, supportive counseling, crisis intervention, primary and secondary prevention education, health promotion assistance, partner/spousal notification assistance and triage to CBO case management as needed.

Quality Assurance

In addition to quality assurance regulations mandated for all MCOs, State law requires that NYS DOH establish additional quality assurances for the HIV SNPs.  The program must reflect clinical standards established by the AIDS Institute (which is part of DOH) and is to be done at least annually.  The law itemizes some minimally required measures, which are:

- Performance and outcome-based quality standards;

- Appropriateness, accessibility, timeliness and quality of care;

- Referrals, coordination, monitoring and follow-up with other medical providers;

- Access to specialty services outside of the plan's network when not available in the network; the distribution of material to enrollees which is culturally and linguistically appropriate and is clear and coherent;

- The usage of an MIS system to support quality assurance activities, which must include enrollment, complaints, encounters and specific performance indicators.

Capacity

NYSDOH will monitor the HIV SNPs to verify that the SNPs have established mechanisms to ensure that provider networks are "adequate and appropriate to meet the medical care and social service needs" of the proposed enrolled population, and to identify gaps in services.  Physician offices must be adequately staffed to "assure accessibility to providers" within prescribed appointment times. If NYSDOH finds that an HIV SNP is deficient in provider capacity, sanctions will be imposed.

SNPs must provide specific member to PCP ratios, which NYSDOH will use to evaluate whether each SNP's capacity is sufficient to handle enrollment levels. In connection with capacity, HIV SNPs must meet a series of appointment standards:

• Urgent medical or behavioral problems within 24 hours
• Non-urgent "sick visits" within 48-72 hours
• Routine, non-urgent, or preventative care visits within 4 weeks
• Baseline and routine physicals within 4 weeks
• Initial prenatal visits within 3 weeks during first trimester, and 2 weeks thereafter
• Initial visit for newborns to the PCP within 48 hours of hospital discharge
• Initial family planning visits within 2 weeks
• In-plan mental health or substance abuse follow-up visits (pursuant to a hospital or emergency discharge) within 5 days, or as clinically indicated
• In-plan, non-urgent mental health or substance abuse visits within 2 weeks
• An ability to accommodate walk-ins, especially for adolescents and substance abusers

In addition, HIV SNPs must assure that at least three of the PCPs that each member may select from are within 30 minutes by transportation.

III. Differences between Medicaid Managed Care and the HIV SNPs

The HIV SNPs shall be required to meet the same requirements as all other MCOs, including regulations on standards of care, licensure and capacity, as well as have the same basic package of services. However, they will have to meet additional service requirements and regulations that shall apply only to the SNPs.

While the SNPs essentially will offer a basic service package similar to the Medicaid Managed Care package, it will offer more extensive coverage than the standard managed care program in some services that have greater utilization rates for HIV-infected persons and will include additional carve-outs. In addition, the authorizing legislation requires that the SNPs have a network of HIV knowledgeable providers available.  As stated earlier, the AIDS Institute has generated guidelines on what constitutes an HIV specialist.

The AIDS Institute is mandating several different and broad-ranging types of case management services, many of which are not readily available to participants in standard Medicaid Managed Care.  While the SNPs shall be required to create linkages with non-network providers for a host of social welfare and family services, more limited requirements are imposed on Medicaid Managed Care MCOs.

Importantly, the capitation and rate setting mechanism for the HIV SNPs differs significantly from the standard Medicaid Managed Care program.  The capitation rate for the HIV SNPs is based upon the cost of delivering services that are unique to persons living with HIV and AIDS, resulting in higher capitation rates for the HIV SNPs.

IV. Recommended Approaches from Other Studies

The U.S. General Accounting Office (GAO) issued a report that reviewed the challenges States face when they incorporate the disabled population into Medicaid Managed Care.⁴ The main conclusions of this report were that States that relied on participants ability to switch providers or disenroll had insufficient safeguards to help ensure quality care, and States that had small programs which focused exclusively on the disabled tended to be "furthest along" in their protections for participants.  Examples of good practices included requiring health plans to designate advocates to help coordinate the services disabled beneficiaries received, and to provide access to specialists trained in care for disabled persons. To what extent recipients of care are offered the opportunity to provide input into the SNPs service system, be it through the AIDS Institute or at the level of each SNP, could become fairly important to providing recipients an opportunity to correct for deficiencies in care and promote good practices.

The report also had very favorable views of  "risk corridor" programs, whereby the amounts of profit as well as the amount of loss a health care plan could face were restrained, thereby "reducing incentives to inappropriately limit services or avoid enrolling high-cost individuals."  Fortunately, the recently released HIV SNP RFA contains both "risk corridor" and "profit ceiling" components. A criticism the report had of some states was for their reliance on standard rate setting criteria for setting capitation rates, based on the average costs of the general population.

Another report generated by GAO concluded that several performance measures and standards of care did not ensure adequate capacity of quality of care.⁵ Patient to primary-care-physician ratios were cited as often inadequate because many physicians had contracts with multiple MCOs, and the indicators often only measured ratios with patients in one particular plan.  And while many states had requirements that plans provide access to specialty services, because there were no established standards for specialists, there was no effective way to measure whether beneficiaries gained access to specialty care when they needed it.

In summary, the May 1997 GAO report concluded that how successful a State's quality assurance standards were determined by how effective they were in using and analyzing the statistical data they received from MCOs, and how detailed they were in their reporting requirements.  Interestingly, the report also concluded that patient satisfaction surveys were not reliable measures of quality, mostly because participants lacked the knowledge that was needed to evaluate whether the care they received (or did not receive) was adequate.

References

¹Chapter 649 of the Laws of New York, 1996.

² In New York City, the local social service district is the New York City Human Resources Administration (HRA).

³ Exempt populations do not have to enroll in Medicaid managed care but may choose to do so if they wish; ineligible/excluded populations are not allowed to enroll in Medicaid managed care and must remain in fee-for-service

⁴ U.S. General Accounting Office, "Medicaid Managed Care – Serving the Disabled Challenges State Programs", U.S. Government Printing Office, Washington, DC, July 1996 GAO/HEHS-96-136.

 ⁵ U.S. General Accounting Office, "Medicaid Managed Care – Challenge of Holding Plans Accountable Requires Greater State Effort", U.S. Government Printing Office, Washington, DC., May 1997, GAO/HEHS-97-86

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New York State's Medicaid Managed Care Law
And Persons with HIV: The HIV Special Needs Plan

October 1999
Matthew H. Lesieur
HIV Health and Human Services Planning Council
Office of the Mayor – AIDS Policy Coordination

Please note that this document is provided for informational purposes only and should not be considered the official opinion of any City agency or department.

Table of Contents

I. Medicaid Managed Care * Coverage: * Enrollment Process: * Coordination of Care: * Quality Assurance * Ineligible / Exempt Participants: * Carve-Outs: *

II. HIV Special Needs Plans (SNPs) * Enrollment * Financing: * Timeline: * NYS Law Mandates * Qualified HIV Providers * Service Package * Basic Benefit Package: * Stop-loss benefits: * Fee-for-Service Benefits: * Fee-for-Service or Network Covered Benefits: * Network Providers (Qualifications and Coverage): * Mental Health and Substance Abuse Treatment Services: * Reproductive Health * Dental Care * Case Management * Quality Assurance * Capacity *

III. Differences between Medicaid Managed Care and the HIV SNPs *

IV. Recommended Approaches from Other Studies *

V.   References *

[History]
[Government]
[References]
[Sites]
[Quality]
[SNPs]

[SNP Paper]