NYS MLTC Data Transparency Project
About this webpage:
Nearly 300,000 New Yorkers depend on home care services from Medicaid Managed Long Term Care (MLTC) plans. This webpage for the first time makes public important data showing how the MLTC plans spend billions of Medicaid dollars to provide necessary Medicaid long term care services that enable New Yorkers with disabilities of all ages to live safely in the community. While the State makes some MLTC data public, there is a huge gap that this webpage aims to fill, by posting selected data from Managed Medicaid Cost and Operating Reports (MMCOR) Reports, obtained through a Freedom of Information request. The data is posted in four interactive visualizations, and can be downloaded for further analysis. NYLAG calls on New York State to make this data public on its Open Data website.
This project was made possible by generous grants from:
The Elder Law & Special Need Section of the New York State Bar Association
-and-
The Fan Fox & Leslie R. Samuels Foundation
The design and implementation of this project was performed by John W. Rodat, whose company, Public Signals, Inc. https://www.publicsignals.com, specializes in transforming raw public data into useful information.
Special thanks are due to Eric C. Smith, who, beginning in 2019, has spent hundreds of hours on this project as a volunteer law intern working with the New York Legal Assistance Group (NYLAG). He will be graduating from George Washington School of Law in 2023.
Many thanks to members of the Advisory Committee that consulted on this project: Peter Travitsky, Eric Smith, Sara Keating, Janet Cohen Sorrentino, Jeanne Kramer, Belkys Garcia, Naomi Levin, Esq., Suzanne de Beaumont, Lindsay Heckler, Valerie Bogart, and Moriah Adamo
Background about Managed Long Term Care (MLTC)
In 2011, Governor Cuomo’s Medicaid Redesign Team (MRT) recommended “managed care for all.” Since 2012, most adult Dual Eligibles (who have both Medicare and Medicaid) have been required to join Managed Long-Term Care (MLTC) plans in order to obtain Medicaid home care services – whether personal care, Consumer-Directed Personal Assistance Program (CDPAP) services, or private duty nursing. MLTC plans are a type of “managed care” insurance plan that contracts with NYS to provide a package of Medicaid services, including community-based long term care services. Click here for a list of MLTC services.
Medicaid has two different models for how services are authorized and paid for. Under the Fee For Service model, the providers are paid directly for each service they provide, but home care services must be authorized first by the local Medicaid program. Under the managed care model, the State pays MLTC plans a monthly fixed capitation rate or “per member per month” premium. The plans decide how many hours of home care to authorize, and which other services to provide for each member. The plan then pays health care providers that they contract with (“in-network”) to provide the services. The plan receives the same fixed capitation rate each month for each member, regardless of the amount of home care or other services the plan authorizes for its members. The capitation rates vary between plans, and may also vary by geographic region. The rates are calculated under a complex formula by the State’s actuaries that take into consideration many factors and are adjusted annually.
- Types of MLTC plans: There are two basic types of MLTC plans. Most members choose “partially capitated” MLTC plans that exclusively provide Medicaid services, keeping their Medicare coverage separate. Some members choose “fully capitated” plans, which combine in one all-in-one plan all Medicare and Medicaid services. There are two types of fully capitated plans – Medicaid Advantage Plus (MAP) and PACE plans. MAP plans combine in one plan a Medicare Advantage Special Needs Plan designed for Dual Eligibles (“Dual-SNP”) with an MLTC plan and add all other Medicaid services. (A third type of fully capitated plan, called “FIDA,” was under a demonstration program that ended in 2019). See more about the types of MLTC plans here.
- Ten Years of Mandatory MLTC Enrollment. Since mandatory enrollment in MLTC plans began in 2012, combined enrollment in all three types of MLTC plans has increased seven-fold, from 43,500 in 2011 to 282,000 in December 2021. (Find current monthly enrollment stats here and here [link to and explain John’s enrollment vi]). Over 20,000 MLTC members were disenrolled from their MLTC plans since August 2020. Before August 2020, adult dual eligibles who entered a nursing home were required to remain in their MLTC plans, or to enroll in an MLTC plan if they had not been enrolled while in the community. Beginning August 2020, MLTC members are disenrolled from their plans after three months in a nursing home, if they have been approved for “nursing home Medicaid.” See this article for more about this change.
VIZ No. xx visualizes the change in MLTC enrollment since 2011. The user may view the changes in enrollment as well as demographics of plan membership by plan, by region, and by plan type.
What Public Data about MLTC Plan Performance is Available – and What are the Gaps?
The NYS Department of Health (DOH) publishes and posts some data, which while appearing to be extensive, is inadequate. First, DOH issues an annual “Managed Long Term Care Report,” (“DOH MLTC Report”), posted at this link under Quality Performance Reports, most recently in 2019. Second, DOH files an annual report with the federal Medicaid agency – CMS – for the state’s 1115 Waiver, which covers not only the MLTC program but all managed care plans in NYS (posted at this link – click on MRT 1115 Demonstration Annual Reports).
Based on two sources – a member satisfaction survey and data from the “Community Health Assessment” (CHA), also known as the Uniform Assessment System (UAS) tool, which is the nurse’s assessment of member needs used by the plan to develop a plan of care. The DOH MLTC Reports contain important data describing members’ functional needs. For example:
- Table 2 shows the percentage of members who had 1, or 2 or more hospital or nursing home admissions.
- Table 4 shows the percentage of members who were independent in “activities of daily living” (ADL) including locomotion, bathing, and transferring. Table 4 also shows the “Nursing Facility Level of Care” (NFLOC) score, which is a composite functional scale from 0 – 46, with 48 showing the highest level of need.
- Table 5 shows, for each plan, the percentage of members who were continent of bladder, continent of bowel, who were cognitively intact, and who showed no behavior symptoms.
- Table 6 shows, for each plan, the percentage of members who live alone.
- Table 7 shows several variables demonstrating the “effectiveness” of care, such as the risk-adjusted percentage of members who did not experience falls that resulted in injury, or who did not have an emergency room visit, in the last 90 days. Also shown are the percentage of members who received dental, hearing and eye exams (services that are in the MLTC benefit package), as well as flu vaccines (which is not covered by MLTC). Like much of the data, the table indicates whether the plan’s score is higher or lower than the statewide average.
- Tables 8 and 12 summarize member satisfaction with care based on a survey.
Much of the data compiled in the DOH MLTC Reports described above is also posted on the NYS Open Data website, which allows the user to filter and download data. Go to https://health.data.ny.gov/browse and type in “MLTC” to see different charts available. For example, “Managed Long Term Care Performance Data” includes most of the data used in all of the DOH MLTC Report tables listed above. Using the same performance data, “MLTC: ADL Stable or Improved by Plan” shows the percentage of members whose ADLs remained stable or improved.
Gaps in DOH MLTC Reports
While the DOH MLTC Reports and the Open Data site may have extensive data about the functional level of MLTC enrollees, these sources say nothing about how the plans responded to those needs, and how the plans spent billions of dollars in premiums. What percentage of members were authorized to receive 24/7 care, or fewer than 20 hours/week of care? Is there a correlation between a plan’s a high average NFLOC score, or with a high percentage of members who lived alone, with the amount of home care the plan authorized? What percentage of members were admitted to a nursing home, and of those, how many returned home with home care services? How much of the plan’s revenue is spent on home care, on nursing home care, and on administrative costs?
The DOH MLTC Reports and Open Data site do include some statewide data on the number of MLTC members admitted to nursing homes, but do not break it down by plan. The 2019 DOH MLTC Report showed 10.3% of all members were then in nursing homes, that 12% of all members had at least one nursing home admission during the year, 66% of which were for permanent placement (Table 2, p. 10), and 12% of all members had at least one hospitalization. The Open Data site and DOH MLTC Reports report “Potentially Avoidable Hospitalizations” for each plan using a different state database tracking hospital stays called SPARCS. ( 2019 MLTC Report at Table 11).
Another shortcoming of the 2019 MLTC Report and Open Data sites is that much of the data is risk-adjusted, which does not provide full transparency. The data should be publicly available both in risk-adjusted form and in its original form.
More About the MRT 1115 Demonstration Annual Reports and their Shortcomings
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This project makes public for the first time data from Managed Medicaid Cost and Operating Reports (MMCOR) that all MLTC plans must file with NYS DOH. See 10 NYCRR § 98-1.16(f – g). Each MMCOR report for MLTC plans has at least 31 tables of data, with detailed financial and service information – from the amount of each plan revenue source and expenditure for every service and administrative cost, to the amount of home care, nursing home and other services provided to members. The MMCOR data is one of the data sources used by the State for rate-setting, but the data should also be available to the public. The data can help consumers and their advocates make individual choices about plans, can be used to hold plans accountable for how billions of public dollars are spent, and to monitor compliance with the Americans with Disabilities Act (ADA), as interpreted in the Olmstead v. L.C. decision of the United States Supreme Court. For example, if a plan is providing comparatively few hours of home care to most members, while admitting more members to nursing homes, this flags potential Olmstead violations. The MMCOR data can also be correlated with the functional data compiled in the NYS DOH Reports and posted on Open Data, described above, to examine the relationship of services provided by the plan with member’s degree of need (i.e as reflected in the Nursing Facility Level of Care “NFLOC” score).
Now, the MMCOR data is available publicly only by filing a Freedom of Information request. Even then, the State releases the MMCOR report data in an unwieldy format that makes comparison of dozens of plan reports virtually impossible for a consumer, their family member or advocate. The plans, either individually or through their trade associations, have the resources to hire data analysts to obtain and analyze the data. See, e.g. https://www.nyshcdata.com/mltc-data/. However, these data compilations are proprietary, and available solely to plans, providers or others for a fee.
This project posts selected MMCOR data in four interactive visualizations that enable the user to observe correlations between different types of expenses or services. The data can be downloaded for further analysis.
- MMCOR Reports Used in This Project. This project posts selected data from the year-end MMCOR reports filed by MLTC and MAP plans for 2017 and 2018. They are posted in an interactive format that anyone can view or download. The online visualizations enable comparisons between plans, between geographic regions of the state, between years within the same plan. The MMCOR report for the fourth quarter of each of those years was used, which includes final data for the entire calendar year. See sample year-end statewide 2018 report for one MLTC plan here. Due to resource limitations and unforeseen delays in carrying out this project, we were not able to include data for 2019 and 2020. However, it is hoped that data for these and later years can be added, or that the State will add MCCOR data to its Open Data website.
- Statewide and regional reports — Each plan files a statewide report, plus a separate report for each of the four geographic regions in the state in which they operate. See chart listing counties in each region here (link to PDF to be posted or insert JPG). (NOTE these regions are used in all of the viz’s so this list of regions should be available to click on in various places on the webpage
Consumer Directed Personal Assistant Program (CDPAP): An alternative Medicaid home care model in which the consumer hires, schedules, trains, supervises and can terminate a “personal assistant,” whose hours are authorized by an MLTC or managed care plan or a local Medicaid program. The personal assistant may be the consumer’s family member (other than a spouse or a parent if the consumer is a minor) and is paid by a Fiscal Intermediary that contracts with the plan or local Medicaid program. In contrast, in the traditional personal care service model, the personal care aide is employed by a licensed home care services agency, under contract to a plan or local Medicaid program. See more here and here.
Combined Home Care Hours: Where a visualization gives the option to view data by this category, the data includes Personal Care services, CDPAP, and home health care.
Incurred but Not Reported (IBNR): Payable medical claims that have been incurred because a legitimate and covered health service has occurred, but the billing process is not yet complete
Medicaid: The Medical Assistance (Medicaid) program is a public health insurance program operated by New York State in cooperation with the Federal government, “with costs shared by the federal and state government, and in some cases, with a local contribution.”
Medicaid Advantage Plus (MAP): A type of MLTC plan that is “fully capitated,” meaning it is funded to provide both Medicare and Medicaid services, including all long-term care services, hospitalization, outpatient care, physician, supplies, etc. MAP and PACE plans provide all Medicaid services. In contrast, MLTC plans provide only long-term care services and a few other discrete services (dental, vision, podiatry, audiology, hearing aids, eyeglasses, non-emergency medical transportation). MLTC members receive other Medicaid services on a fee-for-service basis outside the plan.
Medicaid Managed Care: Insurance plans sometimes known as “mainstream” plans that are paid a monthly premium (“capitation” or “per member per month” rate) by the New York Medicaid program to approve and provide all Medicaid services, including acute, primary and long-term care. These plans are generally restricted to children, families and adults who do not have Medicare or other Third-Party Health Insurance, with some exceptions.
Medicaid Managed Long Term Care (MLTC): Insurance plans that are paid a monthly premium (“capitation” or “per member per month” rate) by the New York Medicaid program to approve and provide Medicaid home care and other long-term care services (see list here) to adult Medicaid recipients who have been determined to need long-term care because of a long-lasting health condition or disability. Most adults who have Medicare are required to enroll in these plans to receive community-based long-term care services. For more information see this article and fact sheets here.
Medicaid Managed Care Operational Reports (MMCOR): Data submitted in quarterly reports by participating MLTC and other managed health plans to the New York State Department of Health. They are the basis of the data visualizations in this application. All MLTC plans are required to file quarterly Managed Medicaid Cost and Operating Reports (MMCOR) with the State, with a separate report for each geographic region in which they operate. The last quarterly report is for the entire year. See 10 NYCRR § 98-1.16(f – g). A sample year-end report for 2018 is posted here.
Medical Loss Ratio (MLR): In these visualizations, MLR is calculated by xxx.
Member Months (MM): Plans report much of the MMCOR data by “member month,” such as the number of months that a member is enrolled, or receives a particular service. This calculation adjusts for turnover so that plans whose enrollees stay enrolled for shorter or longer periods are appropriately compared to other plans. This is especially important when calculating the rates at which enrollees use services. For example, Exhibit A-5 reports the number of “member months” in which the plan provided personal care services in each of seven different groupings of hours/month, ranging from < 80 hours/ month to 700+ hours/month. If the plan gave 700+ hours of personal care to 100 members for 2 months in the year, it would be misleading to say that 100 members received 700+ hours of personal care. Instead, the plan would report it provided 700+ hours for 200 member months.
Member Years (MY): Member Years = Member Months divided by 12. We have divided the number of member months by 12 to approximate the number of members who are enrolled in a plan or are receiving a particular service. If the plan reports providing 700+ hours of personal care in 200 member months, for example, this would be shown as 16.7 member years (200/12). By using this formula uniformly in every instance where the plan reports “member months,” it gives a fair representation of the number of members authorized for a particular service. It standardizes plan enrollment figures to account for different enrollee turnover rates and mid-year changes in service amounts, and is intended to be less technical and more readily understood than Member Months.
Nursing Facility (NF) or Skilled Nursing Home (SNF): Nursing Homes
Program of All-Inclusive Care for the Elderly (PACE): a form of managed long-term care that is “fully capitated,” like Medicaid Advantage Plus plans, described here. [cross link to defn MAP]. Note that as the MLTC plans we focused on were partially capitated, it is not clear why some of the MMCOR reports for partially capitated MLTC plans contained some PACE data. This may have been a reporting error, but we chose not to eliminate it.) See more about types of MLTC plans here and about PACE plans here.
Personal Care (PC): The primary type of Medicaid home care service provided in New York State. Most adults who have Medicare must obtain PC from MLTC plans, but some Medicaid recipients obtain PCS from “mainstream” Medicaid managed care plans or from local social services districts. For information on the applicable law, regulations, and policies for authorizing these services in NYS see this article.
Region: Region of New York State. MLTC plans must file a separate MMCOR report for each of four regions in the state in which the plan operates. Each region includes counties as listed here. User may select “STATEWIDE” to view all plans operating in NYS, using the plan’s statewide plan data. Alternately, user may select one of four geographic regions, and only see data for plans operating in that region. If a plan operates in more than one region, only the data for the selected region will appear if one region is selected. The counties in each regions can be viewed in this list. [link to App. A of MCCOR instructions] or insert JPG (pasted above on page 5).
