Meeting regarding CMSs response to tribe's position regarding Centennial Care.

From the Center on Law and Poverty:

I write with an invitation to participate in a critical strategy meeting.  It is anticipated that within a very short period the Centers on Medicare and Medicaid Services (CMS) will make its decision regarding approval/non-approval of the state’s request for an 1115 Waiver to implement the Centennial Care Plan.  This decision will have major impact on tribal healthcare.  In meetings with both CMS and the state’s Human Services Department (HSD), the tribes have clearly stated their many objections to the plan’s design and implementation which have been communicated in direct discussion, numerous position papers and tribal resolutions.  Over the last several days tribes have called up our congressional delegation to protect their interests and on Monday state legislators, Representatives Clahchischillie, Jeff, Louis and Madalena sent a letter to the delegation supporting the tribes’ position.

 

Over many months the New Mexico Center on Law and Poverty has been acting in a supportive role to the tribal effort through the work of our health care attorneys and organizing personnel.  We want to continue to help as much as we can.  We believe that a meeting of representatives of the major tribal groups, Apache, Navajo and Pueblo, is needed so that a unified position can be endorsed that will give direction to all involved.  In addition, questions regarding the Native American response in the event that CMS gives approval to the state’s request need to be addressed, e.g. can we agree on a common response, is there legal recourse to an unfavorable decision, and if so, what are the legal resources that can be brought to bear.  The many people who have been involved in this effort over these many months are fully cognizant of the long-lasting effect of CMS’ decision and what it means for the future development of tribal health care systems. 

 

Initially we planned to have a meeting at our offices in Albuquerque but Ken reminded us that Friday, February 1, is Indian Day at the state legislature and the Apache, Navajo and Pueblo leaders would be there to address the Legislature at 11:00am.  so instead the meeting will be held in Santa Fe on Friday.  We will meet in the House majority leader’s conference room on the first floor following the leaders’ addresses to the Legislature.  The purpose of the meeting is to determine what can be done right now to convince CMS to respond to the tribes’ requests and to consider how we might coordinate our efforts to assure that the tribes secure their rights to determine the design and capacity of their health care systems.  Your participation in the meeting is crucial to the discussions because of your expert knowledge of the issues involved which needs to be shared with the leadership.  The synoptic information you can provide will be important to the decisions that need to be made regarding immediate and future response.  Look forward to seeing you on Friday.

Memorandum

    To: Regis Pecos

From:    April Wilkinson , Program Specialist, Pueblo of Jemez; Quela Robinson, Staff Attorney, NMCLP; Erik Lujan, Policy Analyst, New Mexico Indian Council on Aging

    Re:     Centennial Care Waiver
Date:    January 30, 2013

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1. Background

On April 25, 2012, the State of New Mexico submitted its request for a Section 1115 Research and Demonstration waiver that would, if approved by CMS, result in a 100% Managed Care Organization (MCO) run Medicaid system. The state has named this plan Centennial Care.

The state of New Mexico Human Services Department (HSD) has convened several meetings with I/T/U’s (Indian Health Service/Tribal/Urban Health) to discuss the advantages of its plan. The I/T/U’s have vehemently and consistently opposed this plan. Despite repeated attempts to get HSD to collaborate with I/T/Us to redesign specific elements of the plan, the two entities have reached what the I/T/Us consider to be an impasse. Because the plan was submitted over I/T/U objection to CMS for review and approval, several tribal leaders have called on the tribal consultation policy of the CMS to compel their involvement in tribal consultation regarding the waiver.

On January 23, 2013, CMS conducted the second of two tribal consultation sessions with the I/T/Us of New Mexico. At this session, HSD staff attended and remained stalwart in the design of Centennial Care as proposed. Similarly, the I/T/U’s maintained their opposition to the Centennial Care proposal. CMS has declared that the review team will take the positions of both sides under consideration and will work to make a decision regarding this proposal,  but continues to pressure tribal leadership into delineating and accepting special terms and conditions as compromise positions. A final decision is anticipated from CMS within the next seven to fourteen days. Swift action is needed to prevent a decision from CMS on this piece of the waiver until further consultation can be held between the tribes and CMS.

2. The impact of Mandatory Managed Care and/or “Opt-out” provision for Native Americans under the Centennial Care Waiver
1. All of New Mexico’s previous attempts at mandatory managed care for Native Medicaid recipients have resulted in lost revenue to I/T/U’s
   New Mexico has implemented 3 mandatory managed care programs over the last 15 years and each of these implementations has resulted in a substantially negative impact to the cash flow to Indian Health Service (IHS) facilities, both tribal and federal:
1. In 1997, NM Medicaid began their Salud! Managed Care programs and Native Americans were automatically assigned to Salud! Managed Care organizations that didn't have facilities in tribal communities.  I.H.S. federal facilities lost an estimated $2 million dollars in reimbursements in 1998 due to this policy, but continued to provide the services to the patients.  
2. In 2008, New Mexico awarded the statewide contract for behavioral health services to MCO OptumHealth. IHS/Tribal facilities struggled to obtain contracts and payments for services from Optum.  By December 2009, New Mexico issued OptumHealth a Letter of Direction requiring immediate payment to IHS/Tribal facilities. As of March 2010, OptumHealth still owed federal IHS facilities over $900,000.
3. A more recent example is the NM Coordinated Long-Term Care (CoLTS) program implemented in 2009.  The financial systems of CoLTS contractors did not have the ability to track payments owed to providers. IHS was asked to supply monthly reports to each of the MCO’s as to what was owed with upwards of $300,000 over 60 days past due for over a year.
2. New Mexico’s I/T/U’s will once again lose revenue under mandatory managed care
   In the Pueblo of Jemez, of the patients with some form of 3rd party coverage, 50% are Medicaid eligible. When Jemez health providers treat these patients, the Pueblo of Jemez is able to recover approximately $319/patient/visit, which is called the OMB (Office of Management and Budget) all inclusive rate. Through this direct payment process, which is called Fee For Service (FFS), the Pueblo of Jemez collects approximately $1,807,504 Medicaid reimbursements annually. With those funds, Jemez pays physicians and dentist salaries and procures physical therapy, behavioral health/substance abuse, optometry, podiatry and pediatrician services to be delivered in the Pueblo of Jemez, as both a matter of convenience and to provide a continuum of care for our population. This Medicaid reimbursement comprises approximately 73% of the total annual third party revenue that we stand to lose under a managed care scheme.
   
   If a Native American receives health care through a tribal or Indian Health Service health center, the significant threat posed by the Centennial Care Plan remains the same. Recently, Richie Grinnell, IHS Albuquerque Area Director, documented the Medicaid revenue generated by various service units (SU) across the state. In FY12, over $85 million dollars was generated from serving more than 360,000 people. With these Medicaid revenues, the Indian Health Service pays for the salaries of medical providers and support staff, purchases pharmaceuticals, supplements Contract Health Services, and supports facility infrastructure.
   
3. An “opt-out” solution permits the state and MCO’s to profit from un-provided care
   Under managed care, for every Medicaid eligible patient, including the Native American, who is enrolled with an MCO, the state will pay the MCO upwards of $1700/patient/month (this is the rate paid to the state’s Behavioral Health MCO). This amount is called a per-patient per-month (“PMPM”) or “capitated” rate. This amount is paid monthly regardless of whether or not the patient utilizes or has access to the MCO’s services. In fact, the state Centennial Care contracts with the MCO’s indicate that MCO’s will share fifty percent (50%) of any profit generated in excess of three percent (3.0%) with HSD. Profits that only increase when the PMPM rate is not spent on providing services.
   
   The state has not provided any information about how Native Americans will be identified or enrolled in managed care, how the provision of services will be tracked, or how these individuals will be provided with information about dis-enrollment or how to opt out of their MCO. When MCO’s do not have offices near tribal communities, their staff cannot become acquainted with the clients and the community. This limits the MCO’s ability to provide the education or care coordination required to enroll and provide services to beneficiaries. One tribal community, Ramah, was directly affected by such a situation. In that case, the MCO assigned providers in Farmington to Ramah patients. Allowing beneficiaries to voluntarily choose the MCO and provider that is best for them (the “opt-in”) is the only way to ensure informed consent and that care will actually be provided.
3. Current position of New Mexico tribal leadership on Centennial Care
   Although I/T/Us have different needs and different health delivery systems, the entities have compromised to narrow the redesign elements to the Centennial Care Plan to the following three points:
   
1. Eliminate requirement for Native Americans to be automatically or mandatorily enrolled in a Managed Care Organization. This is to ensure that Native American’s retain their right to choose their own health care system, including the choice to “opt in” to an MCO. However, only 15% of current NA Medicaid eligible individuals have chosen to “opt in” to an MCO.
2. Preserve the mechanism for payment of Medicaid claims for Fee For Service directly between the IHS/Tribal/Urban (I/T/U) and the State of New Mexico at the existing all inclusive OMB rate. Under the current system, when I/T/Us provide a service to a Medicaid eligible patient, the state’s fiscal intermediary makes payment promptly and in full. This system is working and working well. However, the position of the MCO as a “middle man” will create payment issues and administrative burdens that are likely to delay, limit or even eliminate the I/T/U’s ability to collect the Medicaid revenue owed. This becomes an administrative nightmare when I/T/U’s are forced to seek recovery from the state every time that an MCO fails to pay the entire OMB rate (the state is required under the federal American Recovery and Reinvestment Act of 2009 to make I/T/U’s whole).
3. Require that the protection against cost sharing for all Native Americans enrolled in New Mexico’s Medicaid program is clearly written in the state’s waiver; this is regardless of whether they seek care at an IHS or non-IHS facility. Currently, HSD indicates that this issue is “understood” in the application, but the tribes continue to request its clear delineation in the waiver
4. Potential issues for further discussion with CMS

New Mexico tribal and pueblo leadership demand further consultation with CMS. To that end, several ideas for further discussion evolved from the January 23rd meeting. They are not by any means an exhaustive list and will require further vetting with leadership and CMS before they can be called any expression of tribal intent or compromise positions:

1. A demonstration project within Centennial Care as it relates to Native Americans to “test pilot” the initiative before we expose 100% of the Native American population and 100% of the I/T/Us to a full managed care system. The 15% of Native Americans currently enrolled in Medicaid managed care would be one possibility for the pilot population, or I/T/U’s could identify an appropriate population representative of the state’s composition.
2. A single I/T/U’s or group of I/T/U’s could become a managed care organization serving the entire Native American population.
3. I/T/U’s will receive part of the PMPM capitated rate provided to MCO’s for any administrative or care coordination services provided in addition to the OMB rate for services.
4. I/T/U’s will work with the state to develop a tribal specific contract for use with all clauses of contracts between the state and MCO’s impacting Native Americans, and for tribes and MCO’s to use when contracting with each other.