DOH Monthly Briefing – Finance – December 2018

Carl J. Pucci in Finance & Reimbursement

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

1% Restoration/NHQI

The 1% Restoration and 5-year retro impact of the NHQI have been processed via Medicaid cycles #2152 (12/5/18 check date) and cycle #2153 (12/12/18 check date). Members are urged to access the DOH payment link to track and reconcile their payments to the DOH supporting files. Paper checks have been released for facilities whose 1% Restoration payments were used to offset negative Quality Pool adjustments for both cycles, with respective mailing dates of 12/5/18 and 12/12/18 (see DOH transmittal for further details). For further information related to either cycle #2152 or #2153, members are requested to contact CSRA directly at 1-800-343-9000, or email DOH at

In addition, NYSHFA has been contacting DOH on behalf of members who are expecting cash flow difficulties as a result of being subject to a 100% check recoupment in upcoming Medicaid cycle #2154 (12/19/18 check release). See DOH DAL.

1/1/19 Notice Rates

DOH released the 1/1/19 notice rates on 11/1/18, as scheduled. (Please reference NYSHFA EXTRA, dated 11/2/18 for details.) In addition to the initial 2019 capital rate, the notice rates contain a 1.5% transformation fund increase (effective 11/1/18) to the operating rate for all providers. (contained in Line 13 of the summary rate sheet.)

DOH will issue a separate 11/1/18 rate package (with DAL) containing the 1.5% transformation fund increase, which is expected prior to the 1/1/19 rate issuance. The 1/1/19 published rate (expected mid-January 2019) will be updated for the July 2018 CMI (see below).

MDS Case Mix Picture Dates

As previously reported, DOH continues to analyze data from both the April 25, 2018 and July 25, 2018 collection periods. DOH has not yet disclosed how the data from both picture dates will be blended but intends to include the July 2018 CMI update in the 1/1/19 rates. DOH remains committed to the CMI Workgroup going forward to analyze MDS historical trends and provide input with respect to future Case Mix periods.

FFS Transition

Limit the Nursing Home Benefit in Partially Capitated MLTC Plans to Three Months

  • DOH submitted request to amend the 1115 Waiver and limit the nursing home benefit in Managed Long Term Care Plans to three months.
  • After three months, the beneficiary will be involuntarily disenrolled and coverage for nursing home services will be covered by Medicaid fee -for- service IF individual qualifies for institutional Medicaid coverage.
  • Draft letter sent to CMS requesting amendment in September 2018
  • Public comment period extended to November 23, 2018
  • When CMS approves amendment DOH will set up stakeholder meetings to discuss how to operationalize
  • Once amendment is approved, members will receive a Medicaid Choice (MAXIMUS) notice as well as a notice that their benefit is being changed back to fee - for -service. 

Timely Billing Issue

The Associations again raised concern with recent EMEDNY enforcement of timely billing edits, which combined with Medicaid district office determination delays, has resulted in increasing billing denials. DOH will review this issue and NYSHFA will follow-up accordingly.

CRA Reconciliation

The 2017 Cash Receipts Assessment Reconciliation is in final review with DOB and is expected to be finalized during first quarter 2019. The CRA per diems will be updated to a 2017 base (from 2016) for inclusion in the 1/1/19 Rates.

OMIG Audits

The 2015 OMIG Audits are now complete and DOH is presently analyzing audit results prior to issuing related rate adjustments. The 2016 audits continue throughout the Central and Northern regions of the State.

Minimum Wage

DOH is reviewing the 2019 survey data for inclusion in the January 2019 rates. The 2017 minimum wage reconciliation survey should be released to facilities by the end of December.

Shared Savings

DOH plans on releasing further guidance related to Shared Savings during the 1st quarter 2019.

NYSHFA will keep members posted on these important rate-setting issues going forward.


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