Housing Works’ Comments on the Proposals Submitted to and Adopted by the Medicaid Redesign Team on February 24, 2011.

(In addition, Housing Works has one NEW proposal for submission based on action taken yesterday by the Federal Government.)
Associated page numbers are from the 2011-02-24_staff_draft_proposals_with_descriptions.pdf PROPO PAGE PROPOSAL DESCRIPTION HOUSING WORKS’ COMMENTS SAL NUMB NUMBE ER R #10 9 Eliminate Direct Marketing of Special Needs Plans should be exempted. A high percentage Medicaid Recipients by of people with HIV do not understand the benefits of a SNP Medicaid Managed Care Plans option or do not know that they are HIV positive when they choose a managed care plan and therefore have no reason to consider a snp. Moreover, SNP’s cannot participate in autoassignment. It is inconsistent to say that people with HIV can opt out of a mainstream plan for a SNP at any point but not give the SNP’s the ability to market their services. Also, if the goal is to expand to snps to include other currently nonmandated populations for medical home, the SNPS would have to be able to market to these populations. #11 11 Bundle Pharmacy into MMC The rate for this benefit would have to be separately calculated for SNP’s unless HIV medications remain carved out. Otherwise this will have a very bad impact on SNP viability. Moreover, any capitation should take into account the fact that the only generic AV’s are older drugs that are less effective and have greater side effects. It should also take into account increasing evidence that earlier initiation of ARV’s, including immediately upon HIV infection, has significant health benefits as well as a strong prevention effect. Any effort to calculate this benefit based on disease progression would be counterproductive. #15 18 Consolidate all pharmacy feeIt is not clear if this proposal would bring ARV’s and other AIDS 1

for-service proposals into a comprehensive reform package.

Attachm ent #15K

42

Limit opioids to a four prescription fill limit every thirty days.

#17 #18

47 49

Reduce fee-for-service dental payment on select procedures Eliminate spousal refusal.

#24

54

Payment for Enteral Formula with Medical Necessity Criteria

#37

70

Eliminate Case Mix Adj for AIDS Nursing Svcs in CHHA and

medications into the PDL. While Housing Works, alone among AIDS organizations has supported this in the past, we strongly oppose folding in HIV/AIDS medications into the PDL without a “provider prevails” provision. Also, we strongly oppose prior authorization for ARV’s. It is not clear what the benefit of prior authorization is for ARV’s and what reason there would be to decline authorization. If the state’s current standards, which are out of sync with the Federal standard, were used, this could deprive people from seeking early treatment and be a disincentive to early testing. Any pre-authorization requirement would have a negative impact on use of ARV’s for either pre- or post-exposure prophylaxis. While this proposal is probably manageable, initiation of pain management, particularly for chronic pain, may require frequent dose adjustments and /or changes in drugs or drug combinations. The first 30 days of therapy may require more frequent prescriptions for opioids. This should be taken into account in developing by-pass provisions. Housing Works opposes this proposal as it will limit dental access for Medicaid recipients, particularly in places where no dental clinics exists or where art. 28 clinics are oversubscribed. This proposal may have the unintended consequence of driving up the cost of the AIDS drug assistance program if spouses or parents cannot afford the cost of HIV/AIDS medications or may result in people living with HIV not receiving care. Housing Works opposes this proposal as it will have a negative impact on people with advanced HIV or AIDS, especially those with concurrent conditions such as renal failure and cancer. Many of these people are not capable of preparing or may not have the resources to purchase foods necessary for a special diet. Requiring persons to be underweight to receive this benefit would negatively impact health outcomes for these people. Housing Works supports this proposal. As an alternative, the assessment tool should capture behavioral health needs that 2

LTHHCP Programs #41 72 Establish the Public Health Services Corps

#49

76

Reimburse Art 28 clinics for HIV counseling/testing using APGs

#55 #69

80 92

Increase coverage of tobacco cessation counseling Develop and Implement a Uniform Assessment Tool (UAT) for LTC

might make home health care more expensive, requiring better-trained workers or more hours of care. (See comment on #69) Housing Works supports this proposal. However, incentives for persons trained in HIV and/or community medicine must be a part of this proposal and have not been included in the proposal as written. Professionals often avoid certain disease classes, including HIV and addiction, and often avoid classes of people including those who are homeless and active drug users. Housing Works supports this proposal. These rates maintain the ability to bill for a counseling-only visit for someone who elects not to take an HIV test. The test HIV is still billed separately from other billing if there is an additional clinical matter. Rapid testing has been included and has been expanded to allow billing by all providers. While this proposal will result in a slight decrease in payments per test, it has the potential to dramatically increase the number of people who receive counseling and who receive testing. Housing Works supports this proposal. While Housing Works supports this proposal, we are concerned that this assessment adequately account for the varying needs of people living with HIV and other chronic conditions such as mental illness, chronic chemical dependence, and homelessness. We propose that HIV service providers, such as AIDS Adult Day Health Care, be included in the development of this assessment tool and participate in beta testing and piloting it. Housing Works supports this proposal. Housing Works supports this proposal. This proposal should be rewritten to allow a variety of demonstration models for managing behavioral health. 3

#83 #89 #93

101 103 110

Expand SBIRT for alcohol/drug to hospital clinic, DTC and office settings. Implement Health Home for High-Cost, High-Need Enrollees Establish behavioral health organizations to manage

carved-out behavioral health services

Reliance a single BHO for each region will likely negatively impact the ability to develop new models of integrated care, including the development of new co-location and other PACElike models. Housing Works supports this proposal and recommends that the SNP’s be incorporated into this planning and that PACE-like models be a key component for people with multiple chronic conditions. Housing Works opposes this proposal. Where providers follow the law and don’t require payment for patients who cannot afford the co-pay, this is simply a reduction in rates in disguise. Where providers attempt to collect, the co-pays are a barrier to basic and necessary care that, if not provided, will lead to more expensive treatment. Housing Works supports this proposal. Housing Works supports malpractice reform that focuses on improvement of patient safety. It is not clear that this proposal as written, will accomplish this since at least initially the savings come through caps in damages as opposed to changing clinical practice. Housing Works supports this proposal. Housing Works supports this proposal.

#101

114

Develop Initiatives to Integrate and Manage Care for Dual Eligibles Increase Enrollee Copayment Amounts for Medicaid Fee-forService and Family Health Plus; Require Copayments for Child Health Plus Require Hospitals and Nursing Homes to provide Patient Centered Palliative Care Reform Medical Malpractice and Patient Safety

#104

121

#109 #131

125 134

#150 #153

156 159

#196

169

Develop an Automated Exchange/Medicaid Eligibility System Develop innovative telemedicine applications by reducing regulatory barriers and providing payment incentives Supportive Housing Initiative

Housing Works supports this proposal but urges that the initiative consider the full range of populations with chronic 4

#209 #217

173 175

#243

177

Expand Hospice Create an office for development of patientcentered primary care initiatives Explore Models to Implement Accountable Care Organizations (ACOs)

conditions in need of supportive housing, not just to avert nursing home stays but to ensure medical and psychosocial stability and adherence to treatment as well as prevention of disease transmission. There is clearly documented evidence particularly with people with HIV, but also with other homeless and chronically ill populations that housing is a cost-effective intervention that achieves treatment adherence and significantly reduces costs while improving health outcomes. There is compelling evidence that housing of people who are HIV positive and those at highest risk dramatically reduces transmission of HIV as well. Housing Works supports this proposal. Housing Works supports this proposal.

Housing Works has concerns about the role of community based providers and other community-based groups of providers in the ACO scheme, including their ability to operate or have a significant voice in the operation of ACO’s rather than functioning as a subsidiary partner to a hospital or network of hospitals. Housing Works supports this proposal.

#990

186

#1021

188

#1029 #1058 #1451

190 195 206

Explore the Establishment of Reimbursement Rates to Support Efforts to Address Health Disparities Facilitating Co-Located physical health, behavioral health and developmental disability services Enrollment and Retention Simplification Maximize Peer Services Establish various MRT workgroups

Housing Works supports this proposal.

Housing Works supports this proposal. Housing Works supports this proposal. Housing Works supports this proposal. 5

#1458

208

Care Management Population and Benefit Expansion, Access to Services, and Consumer Rights

#1458 Attachm ent 3

216

Streamline Managed Care Enrollment Eligibility Process

Housing Works has concerns that people will be mandated into managed care without a clear understanding of their rights and without the services available. Already, thousands of homeless New Yorkers, for example, are enrolled and even auto-assigned to a plan with even knowing their right to disenroll. Mainstream plans rarely provide them the services they need, apparently willing to accept the ultimately higher costs of care as a “cost of doing business” without regard for the negative health outcomes. The State needs to establish upfront the essential elements any plan must have in place to identify and meet the needs of these discrete populations, including, where appropriate, special needs plans. And the state must ensure that there are sufficient plans who meet those requirements before it mandates managed care enrollment. For example, it would be wholly inappropriate to mandate enrollment of people with HIV in managed care in parts of the state where this would exacerbate a lack of choice in providers or where there are no HIV/AIDS special needs plans. Housing Works supports this proposal in principle but has concerns about the education new enrollees will receive, particularly in light of the elimination of managed care plan marketing funds, to understand their options, including the option to opt for a special needs plan or to opt out of managed care altogether if they meet the criteria to do so. Housing Works would support this proposal if Harm Reduction approaches to addiction treatment were incorporated into it. (See Housing Works’ new proposal below.) Further, Housing Works has concerns about how MATS would integrate with other Health Homes for patients it enrolls. Housing Works supports this proposal. Housing Works supports the development of a two-year budget 6

#4647

223

Expand Managed Addiction Treatment Program (MATS)

#4648 #4651

226 229

Family Planning Benefit Program as a State Plan Service Global Spending Cap on

Medicaid Expenditures

NEW PROPOSAL

for Medicaid. However, we have strong concerns with the rest of this proposal because of the authority it gives DOH to unilaterally cut funding for services during the budget period as well as the fluctuations that enrollment can generate against such a global cap. As it is, the proposed 2% across the board reduction unfairly hits programs that have not seen rate increases in years as well as programs that have had the benefit of year after year trend factors. This wholesale approach to cost reduction gives little reason to believe that future unilateral cuts will be any more fairly allocated or any less subject to the influence of New York’s health care power brokers than they have been in the past. Active drug users are often out of care due to behavior and practice associated with their chaotic life style. They are heavy users of emergency room and impatient care. The Federal government just certified needle exchange as a “drug treatment”. The state should explore using Medicaid to reimburse needle exchange and harm reduction therapy. These interventions are proven to reduce HIV and Hep C transmission. In addition, they dramatically reduce drug overdose and frequently serve as a gateway into abstinence therapy and into coordinated health care.

Charles King, President and CEO Housing Works, Inc. 57 Willoughby Street, 2nd Floor Brooklyn, NY 11201 347-473-7401 king@housingworks.org www.housingworks.org

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