Medicaid Managed Care Update

Carl Pucci in Finance & Reimbursement


The DOH Nursing Home Transition Workgroup met last week to present recommendations from each of its sub-workgroups on Medicaid Managed Care implementation.


Benchmark Fee-For-Service (FFS) rates would be established for a two-year transition period once a county is deemed mandatory for nursing home enrollment into a managed care plan (slated to begin in 2014).  The benchmark rate would include the fully-phased in 2017 pricing rate, a capital benchmark rate, as well as the Universal Settlement, if approved.  NYSHFA has advocated for a full-pricing component as well as the protection of the additional universal settlement funding after the transition period expires.  In addition, we continue to stress the importance of continued CMI adjustments outside of the benchmark rates.  We continue to work with DOH to assist their efforts in taking over collection of the NAMI as well.  The full Nursing Home Transition Workgroup PowerPoint is attached.


DOH stressed that a workflow be established for each managed care population (i.e., does the transition period satisfy industry concerns?)  Permanent placement would still require physician/medical director approval, the five-year look-back would remain unchanged and transfer of asset issues would still need to be addressed.


For network requirements, the proposal is that each Medicaid Managed Care Plan contract with at least the lessor of 1) 30% of nursing homes per county or 2) eight nursing homes per county.  In addition, plans would be required to contract with at least two facilities for specialty services in counties where available.  DOH stressed that plans will need sufficient nursing home contracts to maintain resident access to care.  Medicaid pendings would still be covered under a FFS arrangement, as is the case presently.

Access to Care/Quality

The admissions process will follow existing authorizations, and it is recognized that considerable training and teaching is needed for nursing homes to operate in a Managed Care environment.  Three quality incentive programs are currently proposed:

  • Mainstream Medicaid Managed Care Quality Incentive
  • Nursing Home Quality Pool (NHQP)
  • Quality withhold as part of FIDA demonstration


NYSHFA has developed a summary PowerPoint, highlighting the workgroups recommendations to date.  There is still much work to be done, and questions to be answered.  We will continue to monitor and report on future workgroup meetings as each occurs.  Additional information is found in the Managed Care section of the NYSHFA website under Facility Resources--Reimbursement--Managed Care.

Director, Finance & Reimbursement
518-462-4800 x36