DOH Monthly Briefing – Finance – April 2018

Carl Pucci and Lauren Pollow in Finance & Reimbursement

DOH held its monthly briefing earlier today. The following summarizes the topics discussed. 

2018-19 Executive Budget

Return to Fee-For-Service (FFS)

NYSHFA continues to have fluid discussions with DOH regarding the limit of MLTC Long Term Care Nursing Home Benefit to three months. The State is enacting a “Three Prong Approach” that will cease the auto enrollments of new long-term care nursing home enrollees, limit the Nursing Home Benefit to three months for long term care enrollees once Medicare or other Third-Party insurances are maximized, and finally transition Nursing Home enrollees from MLTC back to Fee for Service. DOH will be providing further guidance to both plans and providers. Target events and dates are as follows: 

    • DOH sent out a March 28 letter to plans notifying them of the 3-month change to FFS;
    • MLTC plans must continue to enroll beneficiaries until May 3rd, when auto-enrollment of beneficiaries will be turned off; and
    • DOH is awaiting CMS approval to change the nursing home benefit for long-stay placements to FFS, they are on track for a July 2018 timeframe.

The Department intends to reconvene meetings with the plans and provider associations on the transition of the benefit back to FFS. They are working on the invitee list and the agenda, which will be primarily focused on the above transition issues. 

1% Restoration 

DOH has finalized the 1% Restoration payment methodology and is awaiting CMS SPA approval prior to funding. The initial lump sum payment should include the first two fiscal years due providers (2014 and 2015), totaling $140M. DOH plans to “double up” payments over the next three state fiscal years (2019/20/21) until the 1% restoration is current. Funding will then continue at $70M going forward in state fiscal year 2022.

2% Quality Penalty 

Since there is no existing methodology to calculate this penalty, DOH will need to gather data, submit a State Plan Amendment (SPA) on the cost-savings, and seeking association input on how to assess a penalty for lower performing nursing homes. DOH is attempting to gather information for a mid-May submission to CMS. Once approved, the 2% penalty would be retroactive to 4/1/18.

DOH has been examining how to define “financially distressed” nursing homes for exemption within the new NHQI quality penalty impacting providers in the lower two quintiles.

Case Mix Index Streamlining 

As a result of increased OMIG audit findings over the last three years, a proposal to streamline CMI and achieve a $15 million gross savings is contained within the Enacted Budget. DOH will be looking to create a workgroup and examine reasonable changes to the case mix process. This will likely involve reviewing information from providers with negative audits, creating a list of best practices, and assisting providers in achieving fewer errors moving forward. 

January 1, 2018 Rates 

The 1/1/18 rates have been posted on the HCS. They include the July 2017 MDS update, the attested 2018 capital rates and the minimum wage adjustment for both employees and contracted staff. DOH has committed to updating the benchmark rate in a timely manner. Attached is the NYSHA member mailing regarding the recent rate posting.

Quality Pool (NHQI)

NYSHFA and the other statewide associations continue to work with DOH regarding the implementation of the four-year retroactive impact of the nursing home quality pool. It is DOH’s intention to first recoup from those providers in the 4th and 5th quintiles. Once the retroactive monies have been recouped, DOH will release funding to facilities in the first three quintiles. No specific timeline for initiating recoupments has yet been provided by DOH. NYSHFA continues to advocate for the 1% restoration funding concurrently with the NHQI to alleviate cashflow concerns.


Although not discussed at today’s briefing, DOH recently proposed regulations to modify the policy on reserved bed days for residents of nursing homes ages 21 and over. The proposed regulations would require nursing homes to hold the same room and same bed without payment. On April 16, NYSHFA submitted a formal response to the Department of Health’s (DOH) proposed regulations. NYSHFA has continually opposed the requirement to reserve the same room/same bed when Medicaid does not reimburse the facility for a resident who is temporarily hospitalized.

As it stands, the 2017 DAL suggested that implementation of new bed hold reimbursement policies would be delayed until the adoption of regulations. It is our understanding that providers will continue to be reimbursed until that time.

Advanced Training Initiative (ATI)

The ATI Application Surveys have been completed and approved by DOH in advance of the anticipated $46M funding. The payment calculations for 223 facilities (all approved), are currently awaiting DOB approval. DOH is expected to adjust rate premiums for MLTC plans, who, in turn, would issue lump-sum payments to eligible providers within 30 days. DOH indicated that a VBP-one contract addendum must be in place to receive ATI funding.

2017 RHCF Deadline

The deadline for submission of the 2017 RHCF is July 31, 2018. DOH anticipates releasing the RHCF software in early May.

Nursing Home Remittance Reports 

With the discontinuance of the FMG FoxPro Reports, DOH is seeking an alternative software solution and has put such a request into EMEDNY. No further timetable has yet been provided by DOH. Although the weekly remittance report includes recoupment detail, the Associations again stressed the unavailability of retroactive adjustment details during this time. Members should contact EMEDNY with specific concerns at


Carl J. Pucci
Chief Financial Officer
518-462-4800 x36 

Lauren Pollow
Director, Government Affairs
518-462-4800 x25