DOH Monthly Briefing – Finance – February 2019

Carl J. Pucci in Finance & Reimbursement

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

November 1, 2018 Rates 

DOH will issue a separate 11/1/18 rate package (with DAL) containing the 1.5% transformation fund increase, which is currently pending CMS SPA as well as DOB approval.

Please note: the 11/1/18 Benchmark rates have been updated to reflect the 1.5% rate add-on.

January 1, 2019

The 1/1/19 rates are currently in Executive review. DOH indicated the Case Mix Adjustment will be updated for the July 2018 MDS, following past practice. Also included in the Operating Rate is the initial 2019 Capital Rate, as well as the 1.5% Transformation Fund Cost of Living Increase.

MDS Case Mix 

As previously reported, DOH has analyzed 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 utilize the July 2018 CMI update in the 1/1/19 rates (as noted above).

With respect to the upcoming July 1, 2019 rates, DOH will be examining all MDS data points within a specific six-month period (as one example of the upcoming process). Citing a 50% increase in case mix acuity over the past three years, DOH requested that the Associations provide direct input to the Medicaid Director as to reasons behind case mix fluctuations in rate-setting vs non-rate-setting census periods, as well as the complexities surrounding the capturing of information related to all MDS submissions. DOH is noncommittal to the establishment of a CMI stakeholder workgroup. 

NYSHFA is actively opposing the related CMI budget cut and will continue its efforts to communicate our message, including meeting with all health leaders of the Senate, Assembly, the Governor’s office and DOB. 

FFS Transition

The State is continuing its efforts to 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.
  • DOH presently responding to CMS request for additional information (RAI).
  • 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. NYSHFA has been in contact with appropriate DOH staff and is seeking member specific examples of delayed ineligibility determination, resulting in denied claims.

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.

Minimum Wage

DOH has collected the 2017 Minimum Wage Survey Reconciliations and is reviewing the data. No specifics on implementation of the reconciliation were released.

OMIG Audits

The 2015 OMIG Audits are now complete and are under executive review. The Associations requested results of the aggregate 2015 audit impact, noting its relevance in relation to ongoing CMI discussions.


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