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Empire Justice Center’s Comments at Medicaid Redesign Team Public Forum in Rochester

New York State Department of Health

January 20, 2011


Prepared by:

Presented by:

Trilby de Jung


Thank you for the opportunity to testify today.  My name is Trilby de Jung and I am the Senior Health Law Attorney for the Empire Justice Center.  We are a statewide legal services organization with offices in Albany, Rochester, White Plains and Central Islip (Long Island).  Empire Justice Center provides support and training to legal services and other community based organizations, undertakes policy research and analysis, and engages in legislative and administrative advocacy.  We also represent low-income individuals, as well as classes of New Yorkers, in a wide range of poverty law areas including health access.

Empire Justice Center serves on the steering committee of Medicaid Matters New York, and we subscribe to the general principles for Meaningful Medicaid Redesign as distributed by Medicaid Redesign Team member Lara Kassel.  Our perspective is squarely in line with that of MMNY; we support reform ideas that will not only save the state money, but improve the experience and health of Medicaid consumers.  I’d like to put several ideas on the table this morning.

Ideas for Eligibility Redesign

First in the area of eligibility, we need to move quickly toward the efficiencies and simplifications required by Federal Health Care Reform.  We need to take advantage of the opportunity to replace the Medicaid eligibility system currently housed within the legacy system operated by the Office of Temporary and Disability Assistance.  We need a system capable of eliminating unnecessary reporting and documentation requirements, and capable of producing Medicaid notices that will empower consumers to take the steps necessary to obtain and maintain their public health insurance.  We also need to consider increasing access to the Medicare Savings Program -- benefits which enable low-income New Yorkers to maximize use of Medicare, a program funded 100% by the federal government. 

Currently, Medicaid applicants in New York face a complex application form, which studies have demonstrated cannot be completed without assistance.  One year later, many lose coverage during renewal due to confusing processes and unclear notices.  Because New York’s Medicaid program is run by 58 different counties across the state, consumers face wide variation in enrollment procedures, systems and attitudes, and many face significant delays in obtaining benefits.  We are currently involved in class action litigation in seven counties on behalf of Medicaid applicants unable to get timely eligibility determinations.  This system is consuming unnecessary state and local resources. 

Federal Health Care Reform brings with it new imperatives for simplicity and transparency in the application process  and creates opportunities for New York State to build significantly on the progress we have already made.  Federal funds are available for creating a new eligibility system.  Legislation passed last session has resulted in the first ever plan for a state assumption of Medicaid administrative responsibilities.  A newly operational Statewide Enrollment Center will begin processing renewals and move on to assume responsibility for eligibility determinations by 2014, the timeline required by the Affordable Care Act.   These actions to improve Medicaid eligibility and recertification processing must be among the top priorities of any Medicaid Redesign effort.

New York must make sure we leave no simplification stones unturned as we design the new statewide systems.  The new systems must be capable of producing notices that make sense to consumers, notices tailored to the appropriate literacy level and the recipient’s actual circumstances, so that consumers will be empowered to take the appropriate action and maintain their health coverage.  We urge the Redesign Team to recommend that the State Department of Health convene a notices redesign committee, with a process modeled after that used in Pennsylvania, by their Deputy Secretary for Public Welfare, who recognized that:

Notices are an underappreciated challenge for states.  If notices currently used in public programs are not revised under federal health care reform, working families will be furious, disappointed and confused when they try to access coverage.

The new system must also be capable of eliminating unnecessary reporting requirements.  New York won approval for twelve months of continuous eligibility for adult Medicaid enrollees even if their income increases, but counties are continuing to require that applicants report changes in income during that 12 month period.  This is an unnecessary burden for Medicaid enrollees and an inefficient use of county staff time.  Our new systems must be capable of sorting exclusions from the new 12 month continuous eligibility so that interim reporting requirements can be eliminated for the bulk of enrollees.  Also, new systems must improve upon paper tracking methods currently used to verify expenses incurred by medically needy consumers who must prove they have met their “spend down” each month in order to activate their Medicaid coverage.

New York should also explore whether there are some program expansions that could save state dollars.  Both the District of Columbia and the state of Maine have raised eligibility levels for their Medicare Saving Programs, programs that help Medicare eligible residents afford Medicare premiums and cost-sharing.  We should consider a similar move in New York in order to maximize Medicare as a payer for our low-income elderly and disabled, a population with complex health care needs that can consume significant state resources.

Ideas for Service Delivery Redesign

In order to maximize revenue, priorities for service redesign will need to be responsive to the opportunities presented in the Affordable Care Act.  Empire Justice supports New York’s efforts to set up health homes for consumers with complex health needs.  Health homes hold promise as a means of capitalizing on an enhanced federal match and reducing service fragmentation.  Another model the federal government expressed interest in funding is integrated care for dual eligibles.  North Carolina has a pilot project underway that is worthy of exploration.

But consumer groups must be included in discussions about these new designs going forward.  Testimony at the regional public meetings has demonstrated a strong interest in Medicaid redesign and provided a plethora of creative community ideas.  In fact, stakeholder engagement is one of the federal government’s criteria for selection in its current solicitation for state proposals for dual eligible service integration.  If New York plans to take advantage of this opportunity for federal funding, however, consumer groups have yet to be approached for involvement.  

We urge the Redesign Team to develop a consistent standard for consumer input into service redesign for vulnerable Medicaid consumers, a standard that includes consumer stakeholders in discussions about potential directions, informs them as models are constructed, and provides an opportunity for input on specific programs before proposals are submitted to the federal government for approval.  

The Redesign Team should also recommend consumer input into New York’s Medicaid managed care program, a program we currently rely upon to deliver savings in some 20% of Medicaid spending.  The program has recently been expanded to include the disabled and elderly, which will present a challenge in terms of maintaining quality services.  As the program expands, it is increasingly important to articulate clear standards for important program elements such as prior authorization, case management, prevention education and follow-up for patients who miss appointments, so that plans are consistent in their coverage of these critical services and patients are able to negotiate the system.  Rather than set policy during contract negotiations with the plans, we should put standards in place that will serve as an underlay to contract negotiations and ensure meaningful care coordination, adequate networks and consumer protections. 

We suggest that the Redesign Team point to an existing body as the appropriate mechanism for gathering consumer input into standards for Medicaid’s managed care program.  The Medicaid Managed Care Advisory Review Panel (MMCARP) was created by statute to provide the Department of Health with input and guidance on its managed care program.  Empire Justice Center is represented on this Panel, as are several other consumer advocates and industry representatives.  We urge broader use of the MMCARP going forward, as a place where standards and proposed policy changes can be discussed before they are finalized. 

Finally, in the area of rate reform, we urge a similar attention to public accountability and transparency.  Providers serving vulnerable communities will always need more support from public dollars, and rate reform should be carefully targeted so as to ensure their survival.  One means of accomplishing this goal is to adjust the money that goes to providers to take into account the mix of patients served, as has been urged for the hospital medical home demonstration program included in New York’s current 1115 waiver proposal.  In addition, Medicaid funds that are supposed to be targeted to uninsured patients should be linked to services actually provided, as is currently the case for 10% of New York’s Disproportionate Share Hospital funds.  We urge more vigorous use of these types of accountability mechanisms in order to make sure that our precious Medicaid dollars go where they are needed most.