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Nursing Home Reimbursement Update

The wait for rate adjustments continues for nursing home providers as various Medicaid payments work their way through the executive approval process. After resolving a hospitalization data issue that has delayed release of the 2018 Nursing Home Quality Initiative (NHQI) scores, the Office of Quality and Patient Safety is now grappling with concern about reported staffing hours. Highlights of the monthly associations meeting with the Department of Health (DOH) on reimbursement issues held on May 14th are outlined below.

Jan. 1, 2019 Rates. The January 2019 rates await final executive approval. Once approved, DOH will post rate sheets on the Financial Gateway section of the Health Commerce System (HCS) and forward the schedule for payment. Despite requiring homes to upload April and July picture date rosters last fall, DOH used the Minimum Data Set (MDS) data associated with the July 25, 2018 picture date to calculate the Case Mix Index (CMI) reflected in the final Jan. 1st rates. Other than an update to the CMI, for most homes, the rate should be the same as the draft initial Jan. 1st rates distributed last November. Members can get a close estimate of their rate by entering their July 2018 CMI and their add-on amounts from their draft initial rates into the LeadingAge NY Rate Template (available for download here). We remind members that line 13 on the first page of the Jan. 1, 2019 draft initial rate sheet contains per-day add-ons for both 2019 minimum wage funding and the 1.5 percent labor cost adjustment funded with managed care conversion dollars enacted in the 2018-19 State Budget.

Because the 1.5 percent adjustment is effective Nov. 1, 2018, providers can also expect to receive Nov. 1, 2018 rate sheets that mirror their July 2018 rate sheets but include a 1.5 percent increase to the operating component on line 13. Subject to federal approval, the increases are scheduled to remain in the rates at a constant amount until March 31, 2022. Once approvals are received, the rates will be paid retroactive to their effective dates.

Also awaiting final approval are:

  • updated July 2015 and January 2016 rates reflecting findings of the Office of the Medicaid Inspector General (OMIG) MDS audits;
  • the removal of any CMI constraint affecting the July 2015 and January 2016 rate periods; and
  • payment adjustments reflecting reconciliation of 2017 cash receipts assessment payments.

As they await approval of the above rate packages, DOH rate setting staff have begun discussions on other payments and rate adjustments, including the final payment of the Universal Settlement, the 1 percent supplemental payment that will distribute $140 million based on annual Medicaid revenue, and the 2018-19 and 2019-20 Advanced Training Initiative (ATI) distributions, for which homes qualified in past years based on their staff retention rates.

Case Mix Workgroup. DOH has reviewed nominees and selected the members of the Case Mix Index Workgroup that is required by the recently enacted state budget. The first meeting is scheduled for next week. The group’s charge is to review recent case mix data and related analyses conducted by the Department with respect to the Department’s implementation of a July 1, 2019 change in methodology. The group will also review the Department’s MDS collection and case mix adjustment processes, seeking to promote a higher degree of accuracy. It is required to complete its work by June 30th. DOH has signaled that their intention is to employ a methodology that uses data from more assessments than are currently used and indicated that they would provide information on whether providers would be required to upload rosters. While the contours of the new methodology are not known, the State’s intention of using more assessments suggests that providers should make sure that all MDS assessments contain accurate and complete data for all items used in CMI calculation. OMIG reports that it has completed field work for 2016 MDS audits but has not yet begun 2017 audits.

Medicaid Cost Reports. DOH is working to resolve technical challenges to make the 2018 Medicaid Cost Report software available as soon as possible. A new schedule has been added to the report that will require homes to provide information on their efforts to educate residents on community living options, resident interest in returning to the community, and data on safe discharges. DOH expects to set a due date 60 days after the report is posted.

To avoid delays in accessing rate sheets and filing cost reports, especially if new staff is involved, DOH is requesting that providers ensure that they have the proper permissions to access the HCS as well as specific sections that may require additional permissions. For example, to access rate sheets, providers need access not only to the HCS, but also to the Healthcare Finance Data Gateway within the HCS. In order to reduce the processing time of granting permissions, DOH is asking that all facilities check that their staff have the proper permissions to access the systems listed below and contact rhcf-hcs@health.ny.gov to obtain permissions where needed:

  • HCS – Health Commerce System
  • Healthcare Finance Data Gateway
  • Nursing Home (NH) Appeal System
  • NH Cost Report – both CPA and Operator certification permissions.

NHQI. Although DOH has resolved the issues with Statewide Planning and Research Cooperative System (SPARCs) data that had delayed the calculation of potentially avoidable hospitalization rates, the Office of Quality and Patient Safety has encountered concerns regarding hours worked data. Provider review of their NHQI results is further delayed as this concern is addressed. When resolved, providers will be asked to review their results, and the related rate adjustments will be reflected in the same payment cycle as the 1 percent supplemental payments (as was done last year).

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