powered by LeadingAge New York

Nursing Home / Medicaid Managed Care Meeting

Last week, the Department of Health (DOH) convened a Nursing Home / Medicaid Managed Care Task Force meeting to re-engage associations in a discussion of issues of common interest to plans and homes. Based on questions collected in advance, DOH developed a set of slides, which staff walked through at the meeting. The slides are available here, and we are very grateful to those members who provided input.

Andrew Segal, Director of the Division of Long Term Care, and John Ulberg, Medicaid CFO, led most of the discussion, with Jonathan Bick (from the Mainstream Medicaid Managed Care side) and Medicaid eligibility staff contributing. Jason Helgerson, State Medicaid Director, was there as well.

Topics included in the discussion are outlined in brief below.

  • DOH reiterated that pharmacy is excluded from the nursing home benchmark rate. For Mainstream Medicaid managed care, in most cases, the pharmacy bills the plan. For Managed Long Term Care (MLTC), the pharmacy bills Medicare Part D or Medicaid Fee-for-Service.
  • Plans are required to adjust rates when benchmark rates are updated in January and July. DOH has refined its systems to help ensure that the state updates benchmark rates in a timely way. We again suggested that the state seek ways to make system-wide retroactive rate adjustments (e.g., the 1 percent rate supplement) outside of managed care to avoid confusion and administrative burden.
  • The state will seek a separate nursing home rate cell and enlist the help of associations, plans, and providers as needed. DOH will focus on this during the second half of the year and will develop a concept paper, signal to the Centers for Medicare and Medicaid Services (CMS) that they are seeking to revisit the issue, and engage the state’s actuary in these discussions.
  • DOH will continue to collect nursing home enrollment from MLTC plans quarterly and reconcile their community member / nursing home member projections to actual enrollment.
  • Plans, not nursing homes, are now notified about resident NAMI amounts. DOH continues to educate local Social Services Districts about using correct N-codes. CMS has firmly rejected the proposal that the state take over NAMI collection. There had been a number of concerns raised regarding the process of establishing institutional eligibility that were not addressed and will be part of a break-out conversation.
  • DOH requested more information about payment delays in cases where a plan requires that Medicare reject a claim and/or that full medical records for permanently placed residents be submitted monthly as a prerequisite for payment. DOH urged plans and providers to work on developing effective systems to ensure that the prompt pay provisions of 30 days for electronic clean claim/45 days for a clean paper claim are met.
  • The state has identified three homes downstate and 27 homes upstate (13 or 14 when adjusted for specialty, CCRCs, and non-Medicaid homes) that have no Medicaid managed care contracts. DOH believes that networks are adequate and does not intend to change current minimum network requirements.
  • DOH intends to provide more information to plans on nursing home quality initiatives and scores and do an analysis of networks regarding the inclusion of high-quality homes.
  • The state reminded participants that general guidance on nursing home / Medicaid managed care issues is provided in the Transition of Nursing Home Benefit and Population into Managed Care document as well as the 2015 Benchmark Rates Letter.

DOH will summarize the discussion and disseminate the document to participants for comment, which will help inform a continuing dialogue. We thank all the members who provided comments in advance of this meeting. We will share a summary of the input we received with the state and encourage homes and plans to continue notifying us of any concerns, especially emerging concerns, related to nursing home-Medicaid managed care dynamics.

Contact: Darius Kirstein, dkirstein@leadingagny.org, 518-867-8841