NYAPRS’ First Look at NY’s FY 2020-21 Budget Agreement

NYAPRS’ First Look at NY’s FY 2020-21 Budget Agreement
April 3, 2020

Between New York’s budget deficit and the devastation caused by COVID-19, this year’s budget process was one of the most pressured and secretive ones in a very long time. Details of both the mental health and Medicaid budgets began to emerge only yesterday, a day after the expected annual April 1 deadline. Following is our best effort to summarize key actions. We will have more to say about it in the coming days

The key questions going in for us were, in a year where New York faced an over $6 billion budget gap:

Could we do better than the initial terms of the mental health budget the Governor released on January 21? In the end, there were not a lot of additions to the Governor’s original funding allocations and levels.

Would the Cuomo Administration find a way to take advantage of federal Virus-related relief funds while making major changes to the Medicaid program? New York’s share of those funds were contingent on no changes in the state’s Medicaid plan and the Governor’s Medicaid Redesign Team’s approach to filling New York’s $2.5 billion budget gap requires major changes in the program. It appears that the state could receive the full $4.5 billion it’s eligible for in federal aid by delaying some impermissible Medicaid changes while at least half the redesign team’s initiatives could be implemented immediately.

NYAPRS agrees with many of our advocacy colleagues that many of the MRT recommendations in this budget “threaten the health, well-being and independence of low-income people and people with disabilities who rely on the program.” See the statement at the end of this report.

We also decry cuts that are essentially imposed on low income New Yorkers when the state could and should have increased taxes on wealthy residents.

The budget also grants extraordinary fiscal powers to the Governor that allows him to withhold or change funding levels if he determines that during the year there won’t be sufficient revenues won’t be enough to meet expenses. If that happens, he can unilaterally cut spending if “such action is necessary to respond to the direct and indirect economic, financial and social effects of the Covid-19.” Which means that all of the allocations below could change later in the year depending on the state’s finances.

The new budget calls for up to $8 billion in short-term borrowing, although it is unclear how much New York will borrow on that basis, largely because access to the bond market has grown more restrictive during the economic meltdown.

HUMAN SERVICES

Across the Board Increases for NY’s Human Services Agencies
Despite an extraordinary coming together of over 40 statewide and regional advocates for the state’s behavioral, health and social services organizations, the goal of an across the board 3% increase for each of the next five years (“”3for5) was not funded this year.

Great thanks are due to each of the campaign’s organizers, board and members for each of our relentless and inspiring efforts and especially to our leader Glenn Liebman, CEO of the Mental Health Association in NYS.

Together, our campaign made very impressive progress as the Governor and state legislators and both the Capital and local media came to fully understand, and in many instances, supported our request. I haven’t seen this level of focus and collaboration since the passage of the original Community Reinvestment Act.

Special thanks are also due to all of the passionate supporters from the NYAPRS membership who advocated across the Capital and Legislative Office Building wearing “3for5” hats at our February 22nd Legislative Day.

You can count on our alliance to renew our efforts to win “3for5” next year and, in the meantime, our group is still working to preserve this great effort by attempting a national strategy to gain more funding for human services agencies in the next and fourth federal Stimulus package.

MENTAL HEALTH

In the end, the Governor and Legislative leaders provided only a little more than what was in the Governor’s original mental health budget proposal as follows:

Mental Hygiene Workforce Increases:
In the end, we were able to hang on to the increase for the OMH, OASAS and OPWDD nonprofit workforce which comes in two rounds, a 2% increase starting this past January and another 2% that is about to be released. Nonetheless, we are greatly disappointed that increases were not afforded to the entirety of our human services agencies and, as promised, will again make that our primary goal in the coming year.

Housing Increases:
the $20 million housing rate hike that was successfully included in the year’s budget thanks to the ‘Bring It Home’ campaign did make it through. Special thanks to the Association for Community Living and their outgoing executive director Toni Lasicki for their leadership here. Again, great thanks are also due to the spirited efforts of the NYAPRS membership.

OMH Housing Preservation Capital
The budget adds another $60 million in capital to maintain and preserve community-based residential settings that allow people with mental illness to live in the most integrated setting possible.

Unfortunately, the budget crisis made this year the first in five years where there was no new monies for Crisis Intervention Teams and no increases in Community Reinvestment funding for the first time in 24 years.

Once again, we were successful in seeing no expansion in the use of Kendra’s Law court mandated treatment orders (AOT) and no permanence of the legislation.

Behavioral Health Parity:
The budget establishes a Parity Compliance Fund- with funds from penalties imposed on plans for violations of Parity going to the fund that will support CHAMP (the MH/SUD ombudsman program) and other parity implementation and enforcement activities.  The final budget also establishes a “statewide formulary” for opioid dependence and antagonist agents. Drugs would be included on this statewide formulary if they meet a standard of agreeing to the “lowest best price” currently paid for that drug anywhere in the State and would require no prior authorization from managed care plans. Also included as another round of $1.5 million to support the work for the Behavioral Health Parity Ombuds program.

Once again state legislators continued funding for the Joseph P. Dwyer Veteran Peer  to   Peer   Services program at a level of $2,487,500.

Addressing Veteran and Law Enforcement Suicides: 
The FY 2021 Enacted Budget includes $1 million to advance the efforts of veterans, law enforcement and first responders with suicide prevention efforts.

Student Mental Health Program: 
The Budget provides $10 million in funding for grants to school districts to address student mental health to improve student access to mental health resources and assist students who have experienced trauma that negatively affects their educational experience. This program will be administered by the Office of Mental Health and developed in consultation with the State Education Department.

CRIMINAL JUSTICE

Once again state legislative leaders and the Governor have failed to enact solitary confinement reform HALT legislation, an outrage that will continue the state’s cruel policy of placing punishment over treatment and rehabilitation. You can count on NYAPRS and other members of the Campaign for Alternatives to Isolated Confinement (CAIC) to only accelerate our efforts here in the coming months. Yet, in the meantime, we must never forget that thousands will continue suffer the torture of solitary confinement.

They included modifications to last year’s bail reform law. The new modifications will keep cash bail but also expand the roster of serious crimes under which judges could still set bail for defendants to include offenses like sex trafficking and grand larceny, as well for certain persistent offenders.

CAIC issues a statement denouncing “the legislature’s passage of rollbacks to bail and discovery reform today (adding that) these changes are horrible at any time and particularly outrageous in the time of the coronavirus crisis. These politically-driven rollbacks will cause grave injustice and likely result in thousands of more people each day and tens of thousands each year locked in local jails across New York State, predominantly Black people, Latinx people, and other people of color, and many people with mental health needs.  In the pandemic, more pre-trial detention will also potentially cause thousands of deaths in local jails, promote the spread of the epidemic in the community, and impose massive new costs, for unnecessary and harmful incarceration, on New York City and New York’s counties.”

ADULT HOME RESIDENTS

The final budget deal provided another $12.5 million to support the transition of adult home residents in the community. The budget agreement continues funding for their advocacy group CIAD in the amount of $75,000 and another $3.2 million for the EQUAL program that funds clothing, skills training  and social activities for the residents and finances capital improvement projects that will enhance the physical  environment of the facilities.

BILLIONS IN MEDICAID CUTS

Across the Board Cuts of 1.5% are being imposed, which is up from the 1% cut announced in January. We expect that once again, mental hygiene services will be exempted here.

Some of those benefits to health care providers came at the expense of insurers. Health plans will be barred from denying payment for Covid-19 treatment in emergency departments and inpatient hospitalizations through retrospective reviews of medical necessity. Insurers also will no longer be able to deny hospital claims because a facility failed to get preauthorization or submit clinical documentation within 48 hours.

Counties, however, did dodge a major bullet with the final budget that undid a plan by Gov. Andrew M. Cuomo to shift big Medicaid cost onto localities.

Care Management Actions

• Achieve Health Home Rate Efficiencies: re-evaluating the benchmarks for admitting and stepping patients down to lower levels of care management or graduation from a Health Home

• Discontinue Health Home Outreach payments

• Establish Plan of Care Incentive/Penalty Payments

• Managed Care Process Optimization for Higher Risk Behavioral Health Patients (HARP/BHHCBS) which we hope means a lowering a caseload size for our population.

• Addressing Barriers to Opioid Care

Pharmacy Actions

• Transition pharmacy benefit from managed care to fee for service payments

• Reduce coverage for over-the-counter drugs (OTCs)

• Discontinue prescriber prevails in Medicaid fee-for-service pharmacy program and for selected drug classes for managed care plans including mental health medications.

• Reduce drug cap growth by enhancing purchasing power, which we believe means providing the ability to negotiate supplemental rebates and the authority to negotiate value-based agreements with manufacturers.

Transportation Actions

• Discontinue Supplemental Ambulance Rebate Payments to emergency medical transportation (EMT) providers

• Reduce Taxi/Livery Rates

• Carveout Medicaid Transportation from the Managed Long Term Care program and into Fee for Service payments

• Carve transportation out of the MLTC Benefit and into fee-for-service

• Maximize public transit in New York City which we believe is aimed at encouraging the use of public transportation

• Reduce Taxi/Livery Rates

• Implement an Ambulance Diversion/Emergency Support Program

• Create a Community Paramedicine Program, which we believe is aimed at expanding  the roles of Emergency Medical Technicians (EMTs) and Paramedics by providing medical care at home and also providing additional patient health and safety services in consultation with telemedicine.

 Telehealth

• Medicaid System Information Technology & Data Access Modernization

• Consider a State-Wide, Hosted Telehealth Platform to help mitigate interoperability barriers, as well as to enhance broadband to ensure telehealth connectivity in rural areas.

Social Determinants of Health

• Pilot Social Determinants of Health (SDH) Interventions with Proven Return on Investment (ROI)

Long Term Care Actions

• The budget establishes a two-and-a-half-year look-back period to determine eligibility for community-based long-term care services, which is an extension from the current 30-day period. 

• Eliminate Spousal Refusal

• Cap Statewide Managed Long Term Care Enrollment Growth at 3%.

Other Actions

• Duals Integration: integrate services for those with Medicaid and Medicare

• Streamline and Enhance Fair Hearing Process

• Delay Community First Choice Option (CFCO) Services from we believe to from January 1, 2020 to April 1, 2022.

• Reduce Workforce Retraining and Retention funding by 25%

• Offer Non-Medicaid Long-Term Care Programs to encourage delayed enrollment in Medicaid with a private pay option for consumers to purchase on NYSoH

Consumer Directed Personal Assistance

• Complete Request for Offers (RFO)

• Impose moratorium on Fiscal Intermediary advertising

• Implement conflict of interest rules for Fiscal Intermediaries

• Implement protocols, roles and standards for CDPAP consumers and designated representation

• Eliminate requirements by plans and LDSSs to notify consumers of CDPAP benefit availability

• Require that Consumers may only have one Fiscal Intermediary

• Permit personal assistants to provide non-emergent transportation to consumers during approved care hours

Administrative Actions to the Personal Care Services and Consumer Directed Personal Assistance Services (CDPAS)

• Require the Community Health Assessments (CHAs) annually, rather than semi-annually

• Eliminate requirement for monthly care management visits by MLTCs

• Require the CHA and Tasking Tool to consider telehealth as a substitute to care hours

• Permit CHAs to be conducted via synchronous telehealth modalities

• Require a Uniform Tasking Tool that plans/LDSSs use to Determine the Individual’s care plan including the number of hours of care that will be approved

• Centralize and make independent the physician order authorization process (with option for Telehealth to promote access)

• Require an additional level of utilization review for PCS and CDPAS when the requested hours exceed 12 hours per day to ensure the individual can remain safely in the community

• Implement an Electronic Visitor Verification (EVV) by the federal deadline that permits consumer and provider choice

Modify Benefit Eligibility Criteria for Personal Care Services (PCS) and the Consumer Directed Personal Assistance Program (CDPAS) Benefit

• Require that individuals are assessed to need more than limited or greater assistance with more than 2 ADLs in order to receive Personal Care Services and CDPAS, – with an exception for individuals with Alzheimer’s or Dementia who would need to require supervision or greater assistance with more than 1 ADL to access PCS and CDPAS

• To be eligible for enrollment in an MLTC plan, require that individuals are assessed to need more than 120 Days of continuous community based long-term care services and limited or greater assistance with more than 2 ADLs, with an exception for individuals with Alzheimer’s or Dementia who would need to require supervision or greater assistance with more than 1 ADL to access PCS and /CDPAS

• Provide plans flexibility in delivering care management

Medicaid Consumer Advocates Respond to 2021 Enacted Budget
(Albany, NY – April 2, 2020) When Governor Cuomo established his Medicaid Redesign Team – or MRT II – in January, he gave its members the directive that any proposed changes have “zero impact on beneficiaries.” The recommendations approved by the MRT II (with abstention from its one and only consumer representative) are largely included in this year’s budget, and they fall far short of that directive.

In fact, their proposals – which the Cuomo administration itself crafted with no legislative negotiation and limited meaningful public input – will have an immediate and detrimental impact on tens of thousands of New Yorkers. These recommendations represent a misplaced commitment to a broken formula and will cause profound harm to beneficiaries. Many of the changes to long-term care will lead to hospitalization and nursing facility placement.

The enacted Medicaid cuts threaten the health, well-being and independence of low-income people and people with disabilities who rely on the program. These cuts will also hurt the hospitals, community- based health centers and other safety-net services that disproportionately serve vulnerable populations and historically-underserved communities, the very people and providers most impacted by the pandemic we now face. This does not represent the best New York can be.

There are many responsible budget alternatives. Instead of requiring those who can most afford it with little, if any, sacrifice to pay their fair share, the budget is balanced on the backs of everyday New Yorkers coping with a public health crisis and all its ramifications.

Governor Cuomo has said that his budget includes policy reforms that reflect social, economic and racial justice. We believe these changes in Medicaid move us further from those goals.

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“Large numbers of frail elderly and people with disabilities will be deprived of home care by these restrictive standards,” said longtime Assemblyman Dick Gottfried (D-Manhattan) who chairs the chamber’s healthcare committee. “This is unjustified cruelty.”