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What is FIDA and how does it impact nursing home providers?

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FIDA, or Fully Integrated Dual Advantage, is a program that packages Medicare and Medicaid benefits into one Managed Care Plan. The majority of people eligible for FIDA are already enrolled in an MLTC or Managed Long Term Care plan. The New York State Department of Health started sending notices to eligible individuals about their FIDA enrollment options in December 2014. In the Bronx, Kings, Nassau, New York, Queens, and Richmond Counties, eligible participants could be covered by a FIDA Plan as early as January 1, 2015. Residents in Suffolk and Westchester Counties are eligible as early as April 1, 2015.


Eligible individuals, in addition to being 21 or older, entitled to Medicare and receiving full Medicaid benefits, must also require community-based long term care services for more than 120 days or be eligible for (but not yet receiving) facility-based or community-based long term services and supports (LTSS). Beneficiaries have the right to opt out of FIDA; however, if they do not opt out before April 1, 2015, they will be assigned to a FIDA plan.


As a general rule, enrollees in a new FIDA Plan will have a transition period during which they can continue a current course of treatment with their existing provider. After the transition period, the members of the FIDA Plan will be required to see doctors and other health care providers within their FIDA Plan’s network. But there is an important exception to this rule, and it applies to FIDA participants who are residing in a nursing facility.


A FIDA participant who is a resident of a nursing facility can continue to live in that nursing facility for the duration of the FIDA, even if the nursing facility does not participate in the FIDA Plan’s network. FIDA Plans will be required to pay out-of-network nursing facilities the Medicaid fee-for-service rate until at least December 31, 2015 so long as the services being rendered to the nursing home resident are covered by traditional Medicaid.


Please do not hesitate to contact the Nursing Home Reimbursement and Recovery department at Abrams Fensterman with any questions you have about Managed Care Plans or any other reimbursement issues.

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