powered by LeadingAge New York

Nursing Home Reimbursement Update

Earlier today (March 10th), the Department of Health (DOH) provided LeadingAge NY and other associations a status update on several Medicaid funding issues. Members should keep in mind that as part of the process of returning Medicaid payments to the two-week lag, nursing homes will receive no Medicaid fee-for-service (FFS) payments this week (i.e., March 11th week). Brief highlights from the meeting are provided below.

Medicaid Lag and ATB Cut. To complete the return of nursing home Medicaid payments to the two-week lag, DOH will not release a Medicaid payment to homes this week. Payment cycle 2220, with a check date of March 9th, will be released on March 25th. Please note that cycle 2220 will also contain the retroactive adjustment reflecting the 1 percent across-the-board (ATB) payment reduction for services provided on and after Jan. 1, 2020.

January 2020 Medicaid Rates. DOH is preparing the Dear Administrator Letter (DAL) that will be issued soon laying out the dates for nursing homes to upload their July 31, 2019 census roster. Minimum Data Set (MDS) assessment data associated with residents in the home on the July 31st picture date will be used to adjust January 2020 rates for resident acuity (i.e., case mix index (CMI) calculation). The Department is working on strategies to make the roster upload and assessment match correction process more efficient. DOH will provide additional information on these enhancements when they are implemented, which may not be until the following roster submission.

Transition to FFS. The Department is working on guidance for nursing homes regarding the batch transfer of long-term stay residents enrolled in partially capitated Managed Long Term Care (MLTC) plans from MLTC to FFS Medicaid. The new target date for long-term nursing home stay (LTNHS) residents across the state to disenroll from partially capitated MLTC plans is May 1, 2020. The original intent had been to disenroll individuals outside of New York City (NYC) on March 1st and those in NYC on April 1st. As part of the batch disenrollment, residents will be removed from MLTC Medicaid rosters and be added to nursing home Medicaid rosters, allowing homes to bill FFS Medicaid for residents disenrolled from MLTC starting May 1st.

While DOH is working with plans to ensure that the appropriate members are disenrolled, nursing homes should be prepared to assist residents to understand the various notices that they may receive as part of the process. These may come from the resident’s plan, DOH, or from “Medicaid Choice,” the State’s Medicaid managed care enrollment broker. It is important to reassure residents that for most, the change is a background payment methodology change that will not impact their care or their Medicaid eligibility.

Following the batch disenrollment process that will be coordinated by DOH, going forward, disenrollments of residents meeting the three-month threshold will be initiated by individual plans. As we await further guidance from DOH regarding the process, providers should be prepared to:

  • Monitor to make sure that any individuals actively working toward discharge are not inadvertently disenrolled from MLTC
  • Ensure that they notify the district/NYC Human Resources Administration (HRA) and the resident’s plan within 48 hours of an individual determined to be in a LTNHS
  • Continue to assist residents to understand the three-month limitation and related notices that they may receive
  • Check rosters and eligibility systems to ensure that they are able to bill Medicaid FFS for residents being disenrolled from MLTC and to identify potential problems quickly
  • Communicate with plans that directly collect Net Available Monthly Income (NAMI) payments to ensure that NAMI is paid to the appropriate entity when a member is disenrolled

MDS Changes. DOH has been having internal discussions regarding MDS changes scheduled for October 2020 that will no longer collect the requisite data for Resource Utilization Group (RUG)-III category assignment on the main MDS form. The State’s current intent is to continue using RUG-III after the change, and DOH is convening a small group of MDS experts to help them develop a strategy to address the issue.

OMIG Audits. The Office of the Medicaid Inspector General (OMIG) continues to audit 2017 MDS assessment data and is in the process of finalizing the last of 2016 MDS audit reports, which they expect to do by the end of April. Providers have 65 days from the issuance of the final report to request a hearing if they wish to challenge the findings. Once all audits are final, DOH intends to reissue rates for the audited rate periods reflecting audit findings and removing any 5 percent case mix constraints.

2019 Quality Pool. Quality division staff report that they are close to completing the draft 2019 Nursing Home Quality Initiative (NHQI) results. When complete, these will be posted on the Health Commerce System (HCS) for providers to review before they are finalized. These results will rely on Payroll-Based Journal (PBJ) data for determining the staffing quality measure. To ensure accuracy, DOH has been discussing the details of PBJ reporting and result calculations with the Centers for Medicare and Medicaid Services (CMS), which has caused some delay in completing NHQI scores.

Capital Corrections. Homes that saw payment adjustments in Medicaid rate cycle 2218 related to capital corrections should have associated rate sheets posted to the Healthcare Financial Data Gateway section of the HCS next week.

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