"FIDA (Fully-Integrated Dual Advantage) Program for Dual Eligibles Closing Dec. 31, 2019

November 2019 Update - FIDA PROGRAM CLOSING 12/31/2019

2,520 members in the SIX FIDA plans will be assigned to a new plan for January 2020 unless they pick and enroll in a different one before December 20, 2019

WHERE IS FIDA?  Most of the 2,520 dual eligibles still in FIDA plans are in NYC,  except for 12 in Westchester and 175 in Nassau County.    

Some FIDA members already changed plans when they heard FIDA was closing.  The remaining FIDA members are receiving  a series of 3 notices explaining their choices.

1. Early October 2019 Notices -- Members received one of two form notices from their FIDA plans saying that if they do nothing before Dec. 31, 2019, they will be automatically (passively) enrolled into a new plan indicated in the notice â�� effective Jan. 1, 2020. 

There are 2 different form letters because FIDA members are being assigned to two different types of plans that provide Medicaid home care and other long-term care services.  Read about the different types of plans that provide Medicaid long-term care services here and also at the end of this fact sheet.  See the Stateâ��s Phase-out Plan for FIDA.

1. Notice A   -Passive enrollment notice into Medicaid Advantage Plus (MAP) --  Most FIDA members (about 2,400) will receive this notice  that they will be assigned to the  sister  â��Medicaid Advantage Plusâ�� or â��MAPâ�� plan operated by the same insurance company that operates their FIDA plan, if they do not select a different plan by Dec. 20th.   MAP plans provide the same package of services as FIDA, combining a Medicare Advantage plan with MLTC and all other Medicaid services â�� all in one plan.  Plans that combine Medicare and Medicaid services in one are called â��fully capitated.â��   

  See this Medicare Rights Center Fact Sheet about MAP Plans. 

WHO -This notice was sent to members of ElderPlan FIDA,  FIDA Care Complete (Centers Plan), HealthFirst Absolute Care FIDA, VNSNY Choice FIDA Complete, and SWH Whole Health - but only to those SWH members in the Bronx.   All of these plans have a sister MAP plan.  See list of MAP plans for NYC, Nassau County, and Westchester.

2. Notice B  - NON-Passive enrollment into MLTC Plan:  Fewer than 134 FIDA members  received this notice  that they will be assigned to the Managed Long Term Care (MLTC) plan operated by the same insurance company that operates their FIDA plan.   Unlike most FIDA members, they will not be auto-assigned to a MAP plan, but may choose to enroll in one if they wish.   The MLTC plans are called â��partially capitatedâ�� because they provide only Medicaid services, primarily home care and other long term care, but no Medicare services. 

WHO - This notice was sent to members of Riverspring FIDA plan and those members of SWH Senior Whole Health FIDA plan who live in Manhattan, Brooklyn, Queens, or Staten Island. 

If they do not select a different option before Dec. 31, 2019,  these FIDA members will be passively enrolled into both a â��partially capitatedâ��  MLTC plan plus a stand-alone Medicare Part D plan, and will have Original Medicare as of Jan. 1, 2020.  They will no longer be in a Medicare Advantage plan

2. Late October - 60-Day Notice -- New York FIDA 60-Day MAP Notice (PDF) - this was sent to the largest group of FIDA members who received the Notice "A" described above, saying they'd be assigned to a Medicaid Advantage Plus plan if they don't choose a different plan.

3. Late November - 30-Day Notice - New York FIDA 30-Day D-SNP Notice (PDF) - this will be sent to the largest group of FIDA members who received the Notice "A" described above, saying they'd be assigned to a Medicaid Advantage Plus plan if they don't choose a different plan. This notice says they will be enrolled into a Medicare Advantage Dual Special Needs Plan, which is combined with a Medicaid and MLTC plan in one Medicaid Advantage Plus Plan. 

• See  more info on CMS FIDA webpage

What are the options for FIDA members who do not want to be assigned to a plan described in the notice they received?  

Before Dec. 20, 2019, they may choose among the following options for their Medicare, Medicaid, and Medicaid long term care (including home care) coverage:   

1. Select a â��fully capitatedâ�� plan similar to FIDA that combines all Medicare, Medicaid and MLTC services in one plan -  for those who received Notice 1, this could be a Medicaid Advantage Plus  (MAP) plan other than the one they would be â��passively enrolledâ��â��â�� or a PACE plan; Those who received Notice 2 could also choose a MAP or PACE plan.  See list of MAP plans for NYC, Nassau County, and Westchester;  or PACE plans in NYC, Nassau County, or Westchester.   OR

2. Separate their Medicare coverage from their Medicaid and Medicaid home care coverage and either select :
   1. A Managed Long Term Care (MLTC) â��partially capitatedâ�� plan for home care and other Medicaid long term care services  (See list of MLTC plans for NYC, Nassau County, and Westchester)   PLUS
   2. For Medicare coverage, their choice of EITHER a Medicare Advantage plan for all Medicare services and prescription drugs  OR  Original Medicare +  a Part D prescription drug plan
3. For more information on their choices, see these Fact Sheets from Medicare Rights Center:  
   1. MAP (Medicaid Advantage Plus) consumer fact sheet
   2. MAP (Medicaid Advantage Plus) advocate fact sheet
   3. Transitions for FIDA beneficiaries in 2019 - includes description of different types of  plans

TRANSITION RIGHTS:  Regardless of what choice the FIDA member makes â�� MAP, PACE, or MLTC plan - or whether they do nothing, changed plans in October or in the next months, or or are assigned to a new plan for Jan. 1, 2020, the new plan must continue their same Medicaid home care services for 120 days unless the member â��agreesâ�� to a reduction earlier.  The new plan may reduce home care services after 120 days only if the memberâ��s medical condition improves or if they have other changes.  The member has the right to appeal and keep your services the same, without being reduced, during the appeal.  Call ICAN for help or more information 1-844-614-8800.  See more about Transition Rights after a plan closes here.

Background on FIDA    - The Rest of this Article for Historic background only since Program is Closing Dec. 31, 2019

The Afforable Care Act established the Federal Coordinated Healthcare Office, also known as the Medicare-Medicaid Coordination Office (MMCO), which is housed in the CMS Center for Medicare & Medicaid Innovation (CMMI).   This office was charged with more effectively integrating benefits under Medicare and Medicaid, and promoting better coordination between the Federal and State governments.  One of the main vehicles through which the MMCO has advanced this mission is the Financial Alignment Initiative, whereby MMCO partners with State Medicaid programs to create demonstration projects to experiment with combining the Medicare and Medicaid programs into a single integrated benefit for dual eligibles.The Integrated Care Resource Center webpage  includes all state proposals, statistical research and other information. 

Seventeen states, including New York, have obtained Federal approval to create "duals demonstration projects," or "duals demos."  New York's duals demo is also a product of the Medicaid Redesign Team (MRT), a State-based health reform initiative with similar goals to the ACA, but specifically for New York's enormous Medicaid program. FIDA is MRT #101 - to develop initiatives to integrate and manage care for eligible duals - with all documents posted at this link.  New York has opted for a capitated model, meaning that the Medicare and Medicaid benefits will be integrated within the coverage of a private managed care plan.  The demonstration project and the plans participating in it are called Fully Integrated Dual Advantage (FIDA).

Click here for official NYS FIDA demo information.

Click here for links to ADVOCACY by Consumer Advocates on FIDA

What is a FIDA plan?  See   DOH webpage on FIDA

FIDA starts with Medicare Advantage

The starting point for FIDA is Medicare Advantage, a type of private managed care plan available to Medicare recipients.  Medicare Advantage is an optional way for older adults and people with disabilities to receive their Medicare health insurance.  Instead of going to any doctor they want using their red, white & blue "Original Medicare" card, and having the Federal government pay the doctor directly, Medicare Advantage participants must generally limit themselves to providers in their plan's network.  These plans must cover all of the same medical care and services that are covered under Original Medicare, but they may require prior approval for some services and they may charge different amounts of cost-sharing. The Federal government pays the Medicare Advantage plan a fixed monthly amount for each member, regardless of how costly their medical care is.  Then the plan pays its participating medical providers fee-for-service.  This system provides financial incentives for the Medicare Advantage plan to find more cost-effective ways of caring for its members.

All FIDA plans are also Medicare Advantage plans.  The basic structure of how they work and the rights of members are based on Medicare Advantage.

Under Federal law, Medicare recipients must have freedom of choice as to whether to enroll in a Medicare Advantage plan or stay with Original Medicare.  Thus, a Medicare recipient can never be forced to enroll in any type of managed care plan that includes Medicare benefits.

However, the Medicaid program does not contain such a right.  Thus, Medicaid recipients (i.e., the poor) have long been required to enroll in private managed care plans in order to get State-funded Medicaid coverage.  However, until recently, dual eligibles were exempt from Medicaid managed care as well.  Therefore, dual eligibles are one of the last groups in the country who have never been enrolled in managed care.

Medicaid Managed Long-Term Care

In 2012, New York state first began to require a certain sub-set of dual eligibles to enroll in a special type of Medicaid managed care plan.  While they were not required to change how they received their Medicare benefits, they were excluded from fee-for-service Medicaid and automatically assigned to Medicaid Managed Long-Term Care (MLTC) plans.  The group affected by this was only dual eligibles who required community long-term care services (including home care, adult day care, and private duty nursing).  MLTC plans are special Medicaid managed care plans that do not include all Medicaid benefits; only the very expensive long-term care services.  As mentioned previously, many dual eligibles turn to Medicaid because they need long-term care services that are not covered by Medicare.

Thus, there is now a population in New York State of about 135,000 dual eligibles who are enrolled in MLTC plans.  Their plans manage their long term care and some other Medicaid services but not their primary and acute medical care, delivered through Medicare.  Thus they still experience uncoordinated care because their Medicare and Medicaid benefits remain completely separate.  Those in MLTC plans typically have "partially-capitated" plans, which only include the Medicaid long-term care benefits.  This means that they still receive their Medicare coverage through either Original Medicare or a separate Medicare Advantage plan.

Medicare Advantage + MLTC = FIDA

A FIDA plan is like a Medicare Advantage plan combined with an MLTC plan.  The FIDA benefit package includes everything covered by Medicare, plus everything covered by Medicaid (including long-term care).  Thus, FIDA plans are considered "fully-capitated."  Beginning in January 2015, New York state will start enrolling some MLTC participants into FIDA plans offered by the same company as their MLTC plan.

This means that affected individuals will need to go through their FIDA plan to meet all of their medical and healthcare needs, regardless of whether covered by Medicare or Medicaid.  FIDA participants must only go to providers in their plan's network (as with Medicare Advantage).  And the FIDA plan is responsible for both authorizing any medically necessary care, and coordinating among its members various providers.

COMPARE:  Medicaid Advantage and Medicaid Advantage Plus vs. FIDA

FIDA plans are not totally new.  Even up til now, Dual Eligibles have had an option of enrolling in a single plan that combines all of their Medicare and Medicaid services in one managed care plans.  These are called MEDICAID ADVANTAGE Plans (as opposed to MEDICARE Advantage plans) and PACE plans.  The name is misleading because these plans cover MEDICARE as well as MEDICAID services. 

TO make it more confusing, only some MEDICAID ADVANTAGE plans include Medicaid personal care and other long term care services.  These are called MEDICAID ADVANTAGE PLUS Plans.   PACE plans also cover Medicaid long term care services as well as all Medicare services.

People in Medicaid Advantage Plus plans, but NOT PACE plans, in the Demo area, will be subject to FIDA passive enrollment. 

Click here for a chart showing which of these many types of plans are offered by each insurance company in NYS,  posted at  http://www.wnylc.com/health/download/429.    This chart shows plans in the FIDA demonstration area.

Like PACE and Medicaid Advantage Plus, FIDA plans will combine under one managed care plan:  (1) a  Medicare Advantage plan, (2) a Part D prescription drug plan, (3) a Medicaid Managed Long Term Care plan, and (4) a regular Medicaid card covering all other Medicaid services.   FIDA plans will cover not only Medicaid long-term care services, as MLTC plans do, but also cover ALL other medical care covered by Medicare and Medicaid.  In other words, a FIDA member will essentially trade in ALL of their insurance cards -- Medicare (Original or Medicare Advantage), Medicaid, MLTC, Medigap, and Medicare Part D -- and only have one health plan -- their FIDA plan.

On August 26, 2013, CMS approved a "Memorandum of Understanding" (MOU) between NYS and DOH to launch this demonstration program.

WHERE

As a demonstration program, NYS is targeting a smaller group of dual eligibles, not the whole state. The demonstration area is  NYC, Long Island, and Westchester.  

WHO

Not coincidentally, the target group includes ADULT dual eligibles (age 21+) in NYC, Long Island, and Westchester who

• Receive or need MANAGED LONG TERM CARE services -  those adults age 21+  who receive or need community-based long term care services,  AND 

• ALSO - Dual eligibles living in nursing homes or who come to be permanently placed in nursing homes AFTER JANUARY 1, 2015.  (Originally even people who were already in nursing homes at the launch of FIDA would be "passively enrolled" into plans - but this changed in Oct. 2014.  See DOH Update dated Oct. 16, 2014 slide 7.). Note that when a dual eligible first comes into a nursing home - whether for temporary rehab or permanent placement - they are NOT required to enroll in MLTC or FIDA.  Only after they apply for Institutional Medicaid with the 5-year lookback, and that application is accepted, will they receive a letter from NY Medicaid Choice giving them 60-90 days to select a FIDA plan OR to OPT OUT of FIDA.  If they do not OPT OUT, they will be passively enrolled in a plan.

• EXCLUDED - People in the OPWDD and TBI waivers,  those who are receiving hospice services or who live in Medicaid Assisted Living Program will be excluded. 

WHEN  (Updated March 3, 2015 - delay in Region II - Westchester, Suffolk)

After earlier delays, the first "announcement" letters from the State, marketing of the new FIDA plans and "voluntary" enrollment began December 2014, with enrollment effective Jan. 1, 2015 in "Region 1" (NYC and Nassau, and will be later in Region 2 (Suffolk and Westchester).

Passive Enrollment and Opting Out-- Unlike MLTC, enrollment in a FIDA plan is not "mandatory."   MLTC members may choose to stay in an MLTC plan and use their Original Medicare or Medicare Advantage cards for their primary medical care.  However, FIDA will use a "passive enrollment" with the right to "opt-out."  FIDA is rolling out with different schedules in two regions.

REGION  I â�� New York City and Nassau County

Click here to see State's drafts of the enrollment notices listed below, and the Consumer coalition's proposed changes to these notices.

• December  2014 â�� â��Announcement Noticeâ��  sent to MLTC members and nursing home residents  explaining that they may "voluntarily" enroll in a FIDA plan  

  • Notices will roll out over 5 months, with groups selected based on when the renewed Medicaid, or, for duals receiving SSI, based on their birthdate. See schedule in DOH Update 10/16/2014. 

  • NOTE: ANNOUNCEMENT NOTICE had some misleading info - but will no longer be used in the future after April 2015.

    • It says that you can sign up for one of the FIDA plans at any time, but then has a table that suggests that you must sign up for a plan on December 20th before 12 noon in order to join a FIDA plan on January 1st.    The notice should say that you do not have to enroll in FIDA at all, and do not have to enroll in December.  If you want to enroll as of January 1st, then you must sign up before December 20, 2014 at noon.

    • Notice does not explain that FIDA plans have a limited network of providers and that you must use doctors and other providers in the FIDA plan network.

    • Notice does not explain that you will receive a series of notices over the next few months giving you the choice of enrolling in FIDA or OPTING OUT, and that if you do nothing you will be assigned to a plan beginning April 2015.

• Jan. 1, 2015 - Enrollment becomes effective in FIDA plans for people who voluntarily enrolled in December 2014.  People who voluntarily enroll in January, February or March 2015 will become enrolled in the FIDA plan the month after they enroll.  
• Jan. 1, 2015 â�� 90-Day Notice mailed to anyone who did not  join a plan "voluntarily," telling them that they may enroll in a FIDA plan and that if they and do not OPT OUT prior to April  1, 2015,  they will be "passively enrolled" into a plan effective April 1, 2015. 
• Feb.  1, 2015 â�� 60-Day NOTICE OF RIGHT TO OPT OUT or enroll in a FIDA plan - specifies which plan
• Mar. 1, 2015 -  30-Day Notice of right to OPT OUT or enroll in a FIDA plan - specifies which plan (notice revised May 2015)
• April, May, June, July, & August 1, 2015 â�� Those who did not OPT OUT are  automatically assigned - passively enrolled -- into a FIDA plan - divided into five groups of about 7500 people.  For schedule in NYC and Nassau see this DOH PowerPoint.  (BUT NOTE POSTPONED IN WESTCHESTER AND SUFFOLK from schedule in that PowerPoint).
• Which plan?   MLTC members will be assigned to the plan sponsored by their MLTC plan UNLESS they are in one of 3 MLTC plans that are not becoming FIDA plans (HHH Choices, Extended, and UnitedHealth Personal Assist).

Region 2 â�� Suffolk County and Westchester   ******** DELAYED INDEFINITELY AS OF FEB. 27, 2015 ************

• DELAYED from April 2015 â��    Enrollment becomes effective for those who voluntarily enrolled
  • 90-Day Notice mailed that must OPT OUT of FIDA by
• DELAYED from May 1, 2015 â�� 60-Day Notice
• DELAYED June 1, 2015 â�� 30 day Notice
• DELAYED July 1, 2015 -   Those who did not OPT OUT are  automatically assigned - passively enrolled -- into a FIDA plan

Click here to see State's drafts of the enrollment notices listed above, and the Consumer coalition's proposed changes to these notices.

IS FIDA MANDATORY FOR DUAL ELIGIBLES RECEIVING MEDICAID HOME CARE OR NURSING HOME CARE LIVING IN NYC, Long Island or Westchester?

Yes and no.   Unlike MLTC, enrollment in a FIDA plan is not "mandatory."   MLTC members may choose to OPT OUT and stay in an MLTC plan for their home care,  and use their Original Medicare or Medicare Advantage cards for their primary medical care. 

However,  if they do not opt out, or select their own plan by a deadline 90 days after their first enrollment notice, they will be â��passively enrolledâ�� into a FIDA plan selected for them by NY Medicaid Choice.   

HOW DO I OPT OUT?   

After the Announcement Notice is sent in your region (see above), you can call New York Medicaid Choice to OPT OUT.

CALL 1-855-600-FIDA  (1-800-855-3432)   Monday to Friday  8:30 am to 8:00 pm and Saturday from 10:00 am to 6:00 pm. TTY:    1-888-329-1541 

RIGHT TO DISENROLL

Anyone passively enrolled will have the right to disenroll   at any time, but since enrollment is by the month, there may be a delay in which they will not have access to their preferred doctors and other providers, if they are not in the FIDA plan's network. 

WHICH PLANS?

Most of the downstate MLTC plans are seeking to become FIDA plans.  FIDA is essentially an MLTC plan combined with a Medicare Advantage plan.   List of the 22 FIDA contracts is here showing NYC boroughs and counties covered.    Since many plans are listed under different corporate names,  NYLAG has compiled a list of the 22 plans showing which MLTC and Medicaid Advantage Plus plans they are affiliated with in each county in the Demonstration area - NYC, Long Island and Westchester.  Note that some plans do not operate in every borough in NYC. See list showing types of plans offered by each insurance company, with column indicating which will be FIDA plans, posted at  http://www.wnylc.com/health/download/429.

• MLTC plans NOT becoming FIDA plans - United HealthCare, Extended, HHH Choices, Montefiore.

Whether or not to enroll in FIDA - some considerations

1. PROVIDER NETWORKS - Are your preferred physicians, home care agency, hospitals and other medical providers in the plan's network?  If not, you may have to stop using those providers. Note that if you don't join FIDA, you still must be in an MLTC plan for Medicaid home care and other long-term care services -- and your providers of dental care, podiatry, eyeglasses, optometry, hearing aides, and audiology must be in the MLTC plan network.  But MLTC plans DON'T cover most primary and acute medical care - if you opt out of FIDA you would still use your Original Medicare (red white and blue) card for most medical care, with no network restrictions.

2. Prescription drugs -  Medicare beneficiaries may choose how to receive their Medicare Part D prescription drugs - through a stand-alone Part D Prescription Drug Plan (PDP), a Medicare Advantage plan, or FIDA.  Whichever one you select, you want to be sure the plan includes your drugs on it's formulary, at the strengths and dosages you need. 

3. Medigap - Medicare supplemental coverage - If you have a Medigap plan to "wrap around" your Original Medicare benefits, paying your out of pocket Medicare costs such as the annual or hospital Medicare dedectibles and coinsurance, that Medigap plan won't do much good when you have FIDA.   This is because there are no out-of-pocket costs with FIDA - not even the monthly Part B premium.  You might be tempted to drop your Medigap policy if you join FIDA and save money, since the monthly Medigap premium is costly.  That's fine - but CAUTION - if you later decide to disenroll from FIDA and return to Original Medicare, you will not be able to buy a Medigap policy.  This is because of a federal law that bans insurers from selling Medigap policies to Medicaid recipients, since it is essentially duplicate coverage.  However,  if a Medicaid  or QMB recipient already has a Medigap policy, she may renew it or replace it with a different policy.   42 USC 1395ss(3)(3).  So - if you do join FIDA you might consider keeping your Medigap policy active for awhile, while you "test drive" FiDA and see if it meets your needs.

4. Retiree health coverage -  If you or your spouse have retiree health coverage that supplements Medicare, be sure to ask the benefits administrator before you enroll in FIDA.  Enrolling in FIDA may result in TERMINATION of your retiree health coverage, depending on the type of coverage.  This may affect not only you but your spouse or other dependents who may rely on this coverage. 

5. Plus side of FIDA - No premiums, deductibles or copays.   NEWS  MAY 28, 2015 -  Originally, FIDA members were promised that they would not have to pay the Part B premium - even those members whose income was over the limits for the Medicare Savings Program ("MSP")  (These are singles with countable income above $1177 or couples above $1593 who are spending down to the Medicaid level. For them, the Part B premium of $104.90 is normally deducted from their Social Security check).  Now, DOH has clarified that the Part B premium will still be deducted from their checks.  Only if they qualify for an MSP will their Part B premium be paid by the Medicaid program as an MSP benefit.  

As true for any Dual Eligible who sees only Medicare providers who also accept Medicaid, there are no Medicare deductibles or coinsurance payments due in FIDA.  One extra FIDA benefit is that there are NO Part D copayments, while for other Dual Eligibles there are subsidized copayments under Part D - up to $6.60 for a brand name drug.

1. Potential Plus Side of FIDA - coordination of all Medicaid and Medicare coverage under a single health plan, with a care planning team that better coordinates Medicaid and Medicare services and transitions to and from the hospital, etc.

TRANSITION  RIGHTS - FIDA MUST CONTINUE PAST SERVICES & DRUGS AND ALLOW ACCESS TO OUT-of-NETWORK PROVIDERS FOR 90 DAYS

New enrollees in FIDA will face the loss of access to many physicians, other medical providers, and even prescription drugs.  If they were in Original Medicare, they had full access to any Medicare provider. Now they must see only in-network doctors. 

• The FIDA plan will also function as a Part D plan, and may have a more limited formulary than the previous Part D plan.
• FIDA plans must allow participants to maintain  ALL current providers and service levels, including prescription drugs, at the time of enrollment for at least the later of 90 days after enrollment, or until a care assessment has been completed by the FIDA plan.   
  • Caution:   Your doctor or other provider might not agree to participate in the FIDA plan even for the 90-day transition period.  
• FIDA plan has 60 days to complete an assessment for people who transitioned from MLTC, and 30 days for new applicants who never had MLTC.
• FIDA plans must allow nursing home residents who were passively enrolled to stay in the same NH for the duration of the demonstration â�� they cannot make them transfer to a different nursing home. So FIDA plans must contract with ALL nursing homes. 
• The  Dec. 19, 2014 FAQ posted by CMS -- New York Fully Integrated Duals Advantage (FIDA) Provider FAQs -- further explains the Transition Period rights for providers and consumers

INTEGRATED APPEAL PROCESS

• A unique and positive (hopefully) component of NYSâ��s FIDA demonstration is that it will integrate into one system appeals for Medicare and Medicaid services.  Part of the goal of FIDA is to simplify access to care for consumers, so that they donâ��t have to separately navigate Medicare and Medicaid bureaucracies.  See DOH webpage on FIDA appeals and grievances.
  • Consumer receives ONE notice â�� not separate Medicare and Medicaid notices.
• In a victory for advocates, Aid Continuing will be granted in ALL appeals â�� even when MEDICARE services are denied, if the appeal is requested within 10 days of the notice.  If timely requested, Aid Continuing will apply throughout all  stages of the appeal process 
• There are 4 stages of appeal for all Medicare and Medicaid appeals.  Aid Continuing applies through the 3rd stage.

1. Initial appeal is to the Plan.
2. If plan denies internal appeal, may appeal is to the Stateâ��s integrated hearing officer â�� who will hear both Medicare and Medicaid appeals (except for Part D).  This is reportedly going to be a new entity within OTDA (current hearing office)
3. If hearing is lost, may appeal to the Medicare Appeals Council � which will hear Medicaid issues as well as Medicare. Aid continuing applies if timely requested.
4. Federal district court appeal. (NO automatic aid continuing)

CONSUMER PROTECTIONS

• OMBUDSMAN - Independent Community Advocacy Network or ICAN.--Though the state declined federal funding for an Ombudsman program, NYS iis contracting with Community Services Society to operate ICAN - a statewide Ombudsprogram to assist and advocate for consumers navigating FIDA, MLTC, and managed care to obtain long term care.  NYLAG and other non-profits are also participating as part of this program.  The program is called the   Phone:  844-614-8800     TTY Relay Service:  711

  Website:        www.icannys.org

• COSTS to CONSUMER â�� NO copayments allowed, including Part D drugs.  Spend-down (NAMI in NH) will be billed for though.

• Medical Loss Ratio (MLR) â�� 85% of all capitation rates must be spent on services and care coordination, not administration/ profit.  Plan must remit difference to CMS if fails test.

• Right to Disenroll at any time and return to Original Medicare or Medicare Advantage, with Medicaid MLTC for long term care. 

More information will be posted on this website.  For now, see these resources: and State website at http://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm 

• NYS DOH Policy & Planning Update, Oct. 16, 2014
• NYS DOH Frequently Asked Questions (FAQs) - September 2013
• NYS DOH PowerPoint describing the MOU -8/29/13 - http://www.health.ny.gov/health_care/medicaid/redesign/docs/fida_stakeholder_mtg_present.pdf
• NSCLC webinar comparing  dual eligible programs in NYS and other states -- 8/28/13
• CMS -- CMS Press Release,  CMS Fact Sheet
• Link to full Memorandum of Understanding between CMS an DOH
• Link to Three-Way Contract between CMS, DOH and the FIDA plans
• Link to Readiness Review Tool

Earlier History of FIDA Proposal 

On April 25, 2013, NYS amended its final proposal - see Addendum to FIDA Demonstration Proposal and Request for Public Comment. See also --

• 4/24/13 FIDA Demo Proposal Addendum Webinar Presentation (PDF, 225KB)
• 4/24/13 FIDA Demo Proposal Addendum Webinar Audio (WMV, 1.1MB

For links to earlier drafts and consumer comments on them see this article.  As now amended in April 2013, the final proposal will create Fully-Integrated Dual Advantage (FIDA) managed care plans, but scales back the enrollment from the initial draft proposal. 

The April 2013 amendment eliminated an alternative to the "capitated" managed care model, with a separate "Health Home" alternative of the proposal.   This was going to assign dual eligibles who do not receive community-based long term are services to "health homes" if they have one or more chronic conditions such as AIDS. 

• For more info on Managed Long Term Care see this article Mandatory Managed Long Term Care Delayed until July 1, 2012  and this article Managed Long Term Care. 

Advocacy Concerns

See this article for position papers etc submitted by consumer advocates, including  comments to the two draft State proposals.  Organizations that contributed to these comments include the Medicare Rights Center, the Center for Disability Rights, Center for Independence of the Disabled NY, Community Services Society of NY, Empire Justice Center, Legal Aid Society, New York Association on Independent Living, and Selfhelp Community Services, Inc.  The comments raise many concerns about the "passive enrollment" model, in which individuals will be automatically assigned to a plan with the right to opt-out.   Other concerns are voiced about adequacy of the plan's networks of providers -- will people with chronic health conditions have access to specialists they need?  Also discussed are oversight and accountability, grievance and hearing rights, contracting requirements and payment models to incentivize adequate care,  compliance with the Americans with Disabilities Act. 

National Advocacy, Policy Perspective and Experience of Other States  

The National Senior Citizens Law Center has created a website with resources for advocates on the Dual-Eligible proposals -- http://dualsdemoadvocacy.org/.    This website has information on proposals in all fifteen states, federal guidance about the dual eligible demonstrations, plus research and news items in this rapidly moving health policy arena. See, e.g.