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Empire Justice Submits Comments on Revised New York State Duals Proposal

May 18, 2012


On May 17, 2012, the Empire Justice Center submitted comments to the New York State Department of Health on the state’s revised demonstration proposal to integrate care for dually eligible individuals—people with both Medicaid and Medicare.  As a member of an emerging coalition that represents older and disabled Medicaid beneficiaries, Empire Justice joined seven other organizations in praising revisions to the state’s original proposal that would improve the health and well-being of dual-eligibles.  However, our comments also identified aspects of the proposal that remain unclear and made recommendations on elements that should be added, improved or clarified.
The revised proposal promises improvements in cost and quality by including both Medicaid and Medicare services in two distinct models of care, health homes and capitated managed care plans.  New York would begin by enrolling a specially selected population of dual-eligibles statewide into fee-for-service health homes beginning in July of this year.  This group is comprised of about 126,000 dual eligibles who have chronic medical and behavioral health needs and are not receiving more than 120 days of long term support services or services from the Office for People with Developmental Disabilities (OPWDD). 

Then, beginning in 2014, the state would enroll an additional approximately 134,000 dual eligible individuals who are in receipt of more than 120 days of long term care services and either residing in an 8 county, New York City based region, or receiving OPWDD services statewide.  This group would be enrolled into new, Fully-Integrated Dual Advantage (FIDA) plans, which are capitated managed care plans that administer both Medicare and Medicaid benefits.  In total, the affected population would consist of roughly 260,000 dual-eligibles across New York or just over one-third of New York’s dual eligible population.

Empire Justice Center and the coalition’s comments:

  • Supported the proposal’s creation of stakeholder workgroups to address topics such as an integrated appeals and grievances process for Medicare and Medicaid,
  • Urged New York to ensure that beneficiaries are engaged in the development and implementation of the demonstration programs
  • Raised concerns about what is described as “passive enrollment” and how the state will notify beneficiaries of their right to opt out of the health home model or disenroll from a FIDA plan into Original Medicare and traditional Medicaid,
  • Urged the state to build in incentives for community based care in performance measures and rate structures, and
  • Addressed the need for an adequate number of providers within each FIDA plan’s network by suggesting that the state determine which services are accessed most by dual-eligibles and establish network requirements correspondingly, including a maximum patient-to-provider ratio.


The coalition’s comments and New York State’s proposal are posted on NYHealthAccess.