Nursing Home Reimbursement Update
Based on the return to a picture date-based case mix index (CMI) calculation for July 2019 rates, nursing homes will be required to upload their Jan. 30, 2019 resident census roster to the Health Commerce System (HCS) between Dec. 5th and 26th. Certifications are due Dec. 30th. The Dear Administrator Letter (DAL) from the Department of Health (DOH) that outlines the process is available here. Members should take care to ensure accuracy to minimize the possibility of “defaults” – cases where an inability to match a resident with a Minimum Data Set (MDS) assessment results in the resident being assigned the lowest possible score.
As the State goes through the process of recalculating July 2019 rates, it will revert to January 2019 rates retroactive to July 1, 2019. This should reconcile payments made based on the new CMI methodology back to those based on January 2019 rates. We expect the retro adjustment to appear in Medicaid payment cycle 2207 (scheduled for release on Dec. 25th), although we recommend that members be cautious about this timeline until they verify the amount of their Dec. 9th Medicaid check. Please note that these changes are based on the State Supreme Court injunction, not resolution of the underlying case.
The State is in the process of forwarding the fifth and final payment of the Universal Settlement (US) to the Settlement Trustees. The Trustees must still reconcile any Medicaid liabilities being applied to the payments and issue facility checks, a process that is expected to result in checks being mailed to those homes for which Hinman Straub serves as US Trustee (i.e., most LeadingAge NY members) late next week.
Please note that the most recent update to the assessment reimbursement amounts being paid through fee-for-service (FFS) Medicaid has resulted in negative adjustments for many members. For some, it may have generated Medicaid liabilities that DOH has offset from US payments. The issue developed because the estimates that DOH initially used to update the assessment reimbursement amounts in October retroactive to Jan. 1st appear to have been higher than warranted. Members would have seen the result of that initial update in Medicaid payment cycle 2197 (released Oct. 16th) or 2198 (released Oct. 23rd). For most providers, this was a positive adjustment.
When DOH had sufficient data to complete the actual 2018 assessment calculation, it updated the FFS assessment reimbursement being paid in 2019 retroactive to Jan. 1st a second time. The result of that update should have been included in Medicaid payment cycle 2200 (released Nov. 6th) or 2201 (released Nov. 13th). For most providers, this represented a negative adjustment, correcting what in effect was an overstated amount previously. Please keep in mind that this 2019 assessment reimbursement amount is still an estimate and will eventually be reconciled to actual payments, likely in 2021. Because of these repeated assessment reconciliation adjustments as well as recent and forthcoming July 1st rate changes, we recommend that members closely track and validate Medicaid payments, recoupments, and adjustments.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841