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NYS FIDA Fact Sheet for Physicians

(prepared by ALL-AIM MSO)

 

Prepare for changes.  FIDA (Fully Integrated Duals Advantage) is a federal-state demonstration project that alters present state-funded services for Dual eligible Medicare-Medicaid recipients using capitated payments to MCO (Managed Care Organization) insurance plans.  MCOs are highly incentivized to innovate the delivery of healthcare services as well as innovate payments to providers in order to improve efficiency and effectiveness.  FIDA is targeted at the frail older adult to both maintain health and community function, and minimize hospitalizations.  In New York State, this program initially only involves eight downstate counties (Westchester, Bronx, Manhattan, Richmond, Kings, Queens, Nassau, and Suffolk) with the goal of enrolling a potential pool of at least 124,000 Duals who already use LTSS- Long Term Services & Support (110,000 over 65 years old and 14,000 under 65, out of a total 460,000 Duals in these downstate counties, separate from the 295,000 Duals upstate).  Other estimated downstate Duals categories include: 6,000 with intellectual-developmental disabilities (who also must join FIDA) and about 75,000 Duals with chronic medical needs and/or behavioral health needs (about ½ of this group) that do not yet receive LTSS <120 days but who may elect to join FIDA or join a MFFS Managed Fee for Service ‘Health Home’.  Another 75,000 institutionalized downstate Duals (54,000 in medical facilities and 21,000 in mental facilities) are not yet eligible for FIDA. FIDA program is built on the successful pilot PACE (Program for All-Inclusive Care for Elderly) results.

 

FIDA eligibility relates to utilization of services (LTSS or MLTSS Medicaid-LTSS) as well as other criteria related to chronic medical- mental conditions and functionality, ADL (Activities of Daily Living) or IADL (Instrumental Activities of Daily Living). All Duals already using LTSS for >120 days (=4 months) will automatically be enrolled.  LTSS is defined by the following services: 1) Personal Care Aide or Consumer Directed Personal Assistant (Personal Care: Bathing, Dressing, Grocery shopping); 2) Home Health Care Services or Private Duty Services (Home Health Aide, Nurses, Physical therapists); and 3) Adult Day Health Care (ADHC, PACE, Medical-Social Day Care). (Other Services such as transportation to medical appointments and home delivered meals may later become eligibility criteria.)

 

 

Potential candidates FIDA Duals (using <120 days of LTSS) include those having:

(est. 35,000 potentials in Qns & Bklyn)

  • Two coexistent chronic conditions from the following list: (A) cardiac, vascular, pulmonary; (B) major nutritional conditions such as morbid obesity or underweight, diabetes, other major endocrine or persistent metabolic conditions, GU deficits such as incontinence or CKD level >3b-4, chronic GI problems such as ostomies or  colitis; (C) neurodegenerative or neuromuscular disorders, severe visual or otologic disorders, severe vertebral &/or joint-orthopedic disorders; (D) chronic inflammatory conditions such as RA or Lupus, chronic anemias, chronic malignancies, chronic persistent infections.

  • Exceptions are allowed for a single disorder being: chronic mental illness (e.g. dementia, severe persistent depression or severe persistent bipolar disorder, Asperger’s or autism syndrome, schizophrenia) or HIV-AIDS

  • Potential candidates will often have need for functional support which is defined by either ADL or IADL.  

  • ADL can be remembered as related to areas of the house as: 1) Bathroom (inability in toileting; bathing); 2) Bedroom (inability dressing); 3) Dining room (inability eating without assistance); or 4) Living room (inability in ambulation- transferring, being chair-bound- bedfast).

  • IADL can be time-grouped inabilities as: 1) Weekly related (house cleaning, laundry, grocery shopping, using outside public transportation or driving); 2) Monthly related (monthly finances, house repair; 3) Daily related (meals preparation, telephone use, meds preparation).  


 

SNP Special Needs Program type Medicare Advantage Plans or Managed Care Organizations include:

Chronic Condition SNP (C-SNP): Patient has one or more of the following severe or disabling chronic conditions:

  1. Chronic heart failure or Cardiovascular disorders or Chronic lung disorders.

  2. Diabetes mellitus or End-Stage Renal Disease (ESRD) requiring any mode of dialysis or End-stage liver disease.

  3. Chronic and disabling mental health conditions or Dementia or Neurologic disorders or Stroke.

  4. Autoimmune disorders or Severe hematologic disorders or Cancer (excluding pre-cancer conditions) or HIV/AIDS.  

  5. Chronic alcohol and other drug dependence;

Institutional SNP (I-SNP): Patient live in an institution (like a nursing home), or you require nursing care at home.

Dual Eligible SNP (D-SNP):  Patient utilizes exceptional services > 120 days per year.

 

NY State FIDA / MLTC / LTSS online references:

http://www.health.ny.gov/facilities/long_term_care/docs/2012-05-25_final_proposal.pdf

http://www.health.ny.gov/health_care/medicaid/redesign/docs/mltc_legislative_report.pdf

http://www.wnylc.com/health/afile/114/429/

 

Addendum:

2012 Populations of Downstate Counties: [Westchester .96M, Bronx 1.4M, Manhattan 1.6M, Richmond .47M, Kings 2.6M, Queens 2.3M, Nassau 1.3M, Suffolk 1.5M => total 12.1M out of NYS 19.6M]

 

Kings and Queens counties account for 40% of the population of these eight counties (4.9M/12.1m) but probably an excess of MC-MA duals (more so than Westchester, Richmond, Nassau and Suffolk) and therefore probably 45% of the duals in these eight counties.  If we estimate an eight county mandatory conversion of 124,000 and a potential candidate conversion of another 81,000, so that proportionally Kings and Queens should have about 90,000 total candidates (55,000 mandatory and 35,000 voluntary).  By county these estimates are: Queens (25,000 mandatory and 15,000 voluntary); Kings (30,000 mandatory and 20,000 voluntary).  (CenterLight and Archcare (only in Manhattan) are the only experienced NYC PACE programs (pilot precursors to FIDA).

 

NYC area FIDA Plans (having MLTC services) to be available include the following list:

Aetna, Affinity, AgeWell (Parker Jewish), AlphaCare (Magellan), Amerigroup (HealthPlus), AmidaCare, CenterLight, Centers Plan (for Healthy Living), ElderPlan (formerly Homefirst), ElderServe, Extended (CHHA), EmblemHealth (HIP), Fidelis, Guildnet, HHH Choices, Independence Care Systems, Integra (Personal touch), Liberty Health, MetroPlus, Montefiore HMO, North Shore-LIJ Health, Senior Health Partners (Healthfirst/ Managed Health), Senior Whole Health, Touchstone Health, United Healthcare, VillageCare, VNSNY, Wellcare.

 

The advantages of joining FIDA MCOs through COAIM Health IPA and All Medical care IPA, rather than directly would include the following: (MCO: Managed Care Organization)

  • Quicker and larger enrollment of duals population into each provider’s panel. (net larger payments).
  • Faster MCO credentialing (by having our assistance) including substantial help with credentialing of specialists that each provider uses as their referral pattern.
  • Influencing MCO to modify policies (e.g. formulary list, transportation, dental, podiatry, and other services) in order to better satisfy the Dual-eligible patients during their difficult transition.
  • Help achieving quality measures for each MCO as well as help in coordinating the care of patients.  
  • Help with quickly achieving Bonus payments from MCOs & CMS.  (Avoiding conflict of interest with NYS regulations. e.g. bonus payments going family members who may work in office above limit set by state).
  • Being part of COAIM Health IPA and All Medical care IPA confers support in other areas of practice (e.g. IT, EHR) and availability of major opportunities (such as discounted supplies via contracted vendors) and multiple Insurance Plan contracts that may pay better than what’s already available.

 

                                                            (©2013-2014)

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