Twenty months later, HCFA and New York still negotiating terms of Medicaid waiver
HCFA / NY Medicaid Waiver
New York Health Commissioner Barbara DeBuono had been hopeful that the state could begin enrolling 1.2 million of the state’s Medicaid recipients into mandatory managed care "as close to the first of the year as possible."
Now it appears that negotiations with the Health Care Financing Administration (HCFA) on the state’s application for a waiver from Medicaid rules will continue into the twentieth month. At an Oct. 22 briefing in New York City, HCFA officials told representatives of advocacy groups and staffers for elected officials from the state and city it’s unlikely negotiations will be completed before the end of the year— and they could drag on into 1997, according to members of the groups present.
A HCFA spokesman declined to comment on the session, noting that the agency doesn’t comment publicly on the status of waiver negotiations.
New York State Health Department spokesman Robert Hinckley said state officials still think the waiver could be completed soon. "We believe we’re very close," Mr. Hinckley said, adding that the department sent HCFA a response to its original draft of terms and conditions for the waiver some time ago. "We remain waiting for them to get back to us."
The briefing indicates HCFA continues to have concerns about the pace at which enrollment would take place, adequate provider capacity and special needs populations. The advocates said HCFA officials want a two-year phase-in of the program, and would keep a close eye on whether the managed care networks have enough doctors and other health care providers to offer Medicaid recipients adequate care.
State officials have said they want to enroll the Medicaid population in 18 months. Asked if there’s been any change in that position, Mr. Hinckley said, "We are still negotiating the phase-in."
State government sources said HCFA wants the Health Department to phase-in mandatory enrollment by small chunks. For instance, the state would be allowed to implement mandatory managed care enrollment in one borough of New York City and five counties over a four-month period, and, if that phase is completed with no major systemic problems arising, it would be permitted to expand to another similar grouping. State officials want to begin the phase-in by putting New York City and 31 counties, which now have voluntary managed care programs, into the program immediately. But, they say they’re not sure that’s acceptable to HCFA. The state’s total Medicaid population is 3.5
million.
Provider capacity
According to the advocacy groups, HCFA officials said they will require the state to meet a schedule of specific goals before moving ahead with any part of the phase in. These goals include ensuring there is an adequate number of providers available in various specialties, an agreed-upon rate scale for providers (adequate enough to discourage cutting services to keep profits up) and providing outreach services. Outreach will be aimed both at keeping clients informed of services available and at helping them to challenge what they think is improper treatment.
"HCFA will be doing on-the-ground reviews, where HCFA will go out and do visits," said Susan Dooha, senior policy associate with the Gay Men’s Health Crisis and a member of the New York City Task Force on Medicaid Managed Care.
"The state will have to draw up maps to show the distribution of providers," added Michael Kink, legislative counsel to Housing Works, an organization that works on issues affecting homeless people with AIDS or HIV. "HCFA will go on-site and figure out what’s real: At these sites do they have these doctors? Are these unduplicated doctors, or is this doctor listed on six plans?"
The site visits would probably be limited to the main office of the managed care network and perhaps its clinic.
The issue of whether the managed care plans actually have the capacity to handle the more than 3 million Medicaid recipients in New York is critical. Ms. DeBuono herself stepped in last year to slow down the pace of sign-ups in New York City’s voluntary managed care program after advocates complained—and a Health Department investigation confirmed—that some HMOs couldn’t offer all the services they claimed for all clients.
HCFA also plans, according to those who attended the meeting, to take a tough stance on HMO enrollment practices. For example, state law, reflected in the draft waiver terms and conditions, allows face-to-face contact between HMOs and Medicaid clients for the purpose of providing information about their services, but actual sign-ups must be done at a neutral site such as a Social Services office. Advocates may seek even more stringent restrictions on HMO-client contacts.
Focus studies
Due to the huge number of AIDS/HIV and other chronically-ill Medicaid recipients in New York (including the mentally ill), HCFA also will require the state to conduct an extensive study on the care of those two classes of patients.
"Because these waivers are supposed to be for demonstration projects, HCFA requires some studies to be carried out with each grant (of a waiver)," Mr. Kink said. Each state granted a waiver must conduct studies on the impact of managed care on asthmatics, prenatal care, immunizations and other areas of focus. Advocacy groups in New York argued for the AIDS/HIV and chronic illness studies, noting that the federal government should want to make sure the state is complying with the Americans with Disabilities Act (ADA.)
"ADA compliance in this case is not about how wide the doors are," Kink said. "Are there specialists and clinics available to treat (the chronically ill) in this neighborhood? I would say they didn’t comply with ADA if they require someone who lives in Hunts Point (the Bronx) to travel to Manhattan for care."
The issue of whether the managed care plans actually have the
capacity to handle the more than 3 million Medicaid recipients in New York is critical.
While HCFA officials refused to say at the meeting precisely what the studies will require, in other states they’ve focused increasingly on outcomes: What happened to mortality rates, length of hospital stays, number of doctor visits, etc.
"They have assured us they’re not walking away once the papers are signed," Ms. Dooha said. "That’s not to say we’re not worried what will happen. Once the train is racing down the track, it’s hard to know who’s steering and change direction when it’s needed."
—Harvy Lipman
Contact Mr. Kink at 518-449-4207; Ms. Dooha at 212-337-3342; and Ms. DeBuono at 518-474-2011.
Twenty months later, HCFA and New York still negotiating terms of Medicaid waiver
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