Author Archives: Kurt Bratten

Applicability of Fraud and Abuse Rules to the Marketplace Clarified … Somewhat

One of the lingering questions about the Health Insurance Marketplace created under the Affordable Care Act is whether plans on the Marketplace are considered part of a Federal health care program, thus opening up potential liability under the Anti-Kickback Statute. There was concern that the broad language defining a “Federal health care program” would apply to the Exchanges because of the federal tax subsidizes provided to individuals on the private market.  Under 42 U.S.C. 1320a-7b(f)(1), a “Federal health care program” is defined as “any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government.”  This presented the possibility that, by virtue of the inclusion of federal subsidy payments, even private insurance plans on the Marketplace and the state Exchanges would constitute Federal health care programs and necessitate compliance with the entire array of federal legal requirements.    Continue reading

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Filed under False Claims Act, Fraud and Abuse, PPACA

New York and CMS Announce Partnership to Coordinate Care for Medicare-Medicaid Dual Enrollees

Today, CMS issued a Press Release announcing that it is conducting a demonstration project with New York State known as the Fully Integrated Duals Advantage (FIDA) demonstration.  Under this capitated demonstration, approximately 170,000 New Yorkers who are people eligible for Medicaid and Medicare in NYC, Long Island and Westchester County will be able to join a health plan that includes all the benefits of under Medicare (Parts A and B, and Part D)  and Medicaid and additional support for care coordination and community living.  Those who are eligible can opt in starting in July 2014 for community based individuals and October 2014 for individuals living in nursing homes.  Continue reading

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Filed under Long Term Care, Medicaid, Medicare, Nursing Homes

Jason Helgerson Makes MLTC Encounter Data a Priority

At a Managed Care Policy Meeting held last week with managed care plans, New York’s Medicaid Director, Jason Helgerson, spoke about the importance for plans to submit timely and accurate encounter data.  He noted that managed long term care plan submissions are particularly late.  He indicated that if the lack of reporting continues there is the possibility that Statements of Deficiencies (which can result in halting enrollments) will be issued and that the Department of Health will consider referrals to the OMIG for investigation and audit.  The plans responded by explaining that the challenge, in part, is that they are not receiving the required information from the providers (home care, nursing facilities, adult day health care, etc).  Continue reading

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Filed under Managed Long Term Care, Medicaid

The MRT Affordable Housing Work Group Allocates $86 Million to Supportive Housing Initiatives

The Medicaid Redesign Team (“MRT”) Affordable Housing Work Group has allocated $86 million in 2013-14 to fund various supportive housing initiatives throughout the state. The Notice of Funding Availability is available here. Of this amount, $36.376 million is targeted to expand supportive housing units for high cost Medicaid populations. These funding opportunities can be found on the MRT website, as well as on the HCR and OTDA websites. Continue reading

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Filed under Announcements

New York State Releases Funding RFP for Sandy Relief

The Office of Children and Family Services announced that funding is available under the Federal Social Services Block Grant for health and human service providers impacted by Superstorm Sandy.  In total, $200,034,600 in federal Superstorm Sandy Social Services Block Grant (Sandy SSBG) funding will be distributed through a solicitation for proposals. Sandy SSBG resources are dedicated to covering necessary expenses resulting from Superstorm Sandy, including social, health and mental health services for individuals, and for repair, renovation and rebuilding of health care facilities, mental hygiene facilities, child care facilities and other social services facilities. Continue reading

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Filed under Announcements

WellPoint Pays $1.7 Million to Resolve Alleged HIPAA Violations

The managed care company WellPoint Inc. has reached a Resolution Agreement with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR) to settle allegations that it violated the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules. WellPoint agreed to pay $1.7 million in connection with this settlement. The OCR enforces federal standards governing the privacy of individually identifiable health information, including the standards that cover the security of electronic individually identifiable health information. Continue reading

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Filed under HIPAA, Office of Civil Rights

OMH, OASAS and DOH Unveil Behavioral Health Managed Care Update

Earlier this week a team from New York State’s Office of Mental Health (OMH), Office of Alcoholism and Substance Abuse Services (OASAS) and the Department of Health (DOH) presented a webinar describing progress made on managed care program design activities intended to bring behavioral health into Care Management for All. Care Management for All is a program proposed by the Medicaid Redesign Team (MRT) that is supposed to improve benefit coordination, quality of care, and patient outcomes over a range of health care services. Continue reading

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Filed under Behavioral Health, special needs Health and Recovery Plans

Medicaid Director Announces House Oversight Committee Interest in Managed Long Term Care

On June 20, 2013, at the Managed Care Policy Meeting, Jason Helgerson announced that the House Oversight Committee has asked CMS to investigate managed long term care plans related to the use and possible abuse of social day care programs in New York City.  Mr. Helgerson reminded Plans that enrollment from Social Day Care Programs will be reviewed by the Office of Medicaid Inspector General (OMIG) and that referrals have been made to the Attorney General’s Medicaid Fraud Control Unit. He indicated that any premiums paid inappropriately will be recouped. This announcement regarding the proliferation of social day care programs and the individuals enrolled in some of these programs was recently the subject of a New York Times article. Continue reading

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Filed under Announcements, Managed Long Term Care

New York Managed Long Term Care Enrollment Hits 100,000

At its recent meeting on June 13, 2013, the N.Y.S. Department of Health Medicaid Managed Care Advisory Review Panel (MMCARP) was updated about enrollment in Managed Long Term Care.  DOH staff announced that enrollment across the state in 3 types of managed long term care plans has crested the 100,000 mark.  The partial caps, PACE and MAP are the 3 types of Plans available to those who are Medicaid and Medicare eligible, over 21, and in need of more than 120 days of community based long term care services.  Enrollment is now mandatory in New York City, Nassau, Suffolk and Westchester.  Notice letters will be going to residents of Orange and Rockland Counties this week.  In December 2013, DOH will begin mandatory enrollment in Albany, Erie, Monroe and Onondaga Counties.  There are currently 24 partial cap plans, 8 PACE plans and 10 MAP plans approved to operate in various counties throughout the state.  With mandatory enrollment beginning last September in NYC, this Medicaid program has doubled in size.

This post was contributed by Carla Williams.

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Filed under Long Term Care, Managed Long Term Care, Medicaid

Health Planning Committee of the Public Health and Health Planning Council Proposes Significant Certificate of Need Redesign

The Health Planning Committee of the Public Health and Health Planning Council is proposing a significant Certificate of Need (“CON”) redesign. The Committee and Council are expected to make twenty-two (22) recommendations to the Department of Health next week, affecting the CON process.  Five of the recommendations refer to an initiative to shift towards regional planning for CON applications.

New entities – called Regional Health Improvement Collaboratives (“RHICs,” pronounced “Ricks”) – would be responsible for increasing patient experience of care, decreasing the per capita cost of care, reducing the disparities in coverage, and more effectively managing the health of New York’s citizens.  Continue reading

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Filed under Announcements, Public Health and Health Planning Council