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Nursing Home Reimbursement Update

Along with updating January and April 2020 nursing home Medicaid rates, the Department of Health (DOH) has reconciled 2019 cash receipts assessment (CRA) payments and processed 2016 rate adjustments. Here are the adjustments for which nursing home members should be on the lookout. 

2016 MDS Audit Results and Constraint Release. The Office of the Medicaid Inspector General (OMIG) has completed its work on 2016 Minimum Data Set (MDS) audits, and DOH has updated rates for those homes that may have had audit findings. Along with that update comes the release of the 5 percent Case Mix Index (CMI) constraint for those homes subject to the constraint. We expect that audit rate adjustments and removal of the constraint for July 2016 and January 2017 rates will be reflected in Medicaid payment cycle 2267 (check date of Feb. 1st, released Feb. 17th). Rate sheets and the associated Dear Administrator Letter (DAL) have been posted to the Health Commerce System (HCS).

January and April 2020 Rate Update. In late January, DOH posted January and April 2020 nursing home Medicaid rates in the Healthcare Financial Data Gateway section of the HCS. The rates incorporate the CMI calculated using MDS data tied to the July 31, 2019 picture date and apply a 5 percent constraint if the CMI has changed by more than 5 percent relative to July 2019 rates. They also update the basis of the 2 percent quality penalty to 2018 and 2019 Nursing Home Quality Initiative (NHQI) results.

The only difference between the January and April 2020 rates for member homes should be a 5 percent reduction to the capital component. (For-profit facility rates may also reflect a residual capital cut.) The payment adjustments are scheduled to be included in Medicaid payment cycle 2268 (check date of Feb. 8th, released Feb. 24th). DOH has also updated the nursing home benchmark rate list used by managed care plans.

Reconciliation of 2019 CRA Payments. DOH has reconciled CRA payments made and reimbursement received in 2019 to actual amounts. Depending on the facility’s circumstances, the adjustment may be positive or negative and is scheduled to be reflected in Medicaid payment cycle 2269 (check date of Feb. 15th, released on March 3rd). The reconciled amount will also be used to update the CRA reimbursement amount currently paid. The associated DAL is available here, and the back-up calculations are here. We suggest that members review their calculations for accuracy and use the form attached to the DAL to request any needed corrections promptly.

And since the topic is payment adjustments, we remind members that the back-up calculations for the 1 percent supplement and NHQI payment adjustments that were included in Medicaid payment cycle 2262 (checks released Jan. 14th) are available here under the Nursing Home Quality Pool section. Based on previous DOH guidance, NHQI funding is subject to the CRA, while the 1 percent supplement (i.e., reinvestment of .8 percent assessment) is not.

Please contact us if you have questions or concerns.

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