DOH Managed Care Workgroup Update

Esq. Stephen B. Hanse and Carl J. Pucci in Finance & Reimbursement

The Nursing Home Transition Workgroup met earlier this week to revise and clarify a number of policy issues.  As previously noted, new Medicaid enrollees downstate will be required to join a Managed Care Program in March 2014, with upstate enrollees phasing in beginning in September 2014 through January 2015 (depending on county).

Key provisions presented at this weeks’ workgroup meeting included the following: 

  • Extension of the transition period from two to three years.  Providers will thus be guaranteed the current fee for service (FFS) rate (absent an alternative negotiated rate during this time period.)  The three year period would commence in March 2014 for downstate providers, and January 1, 2015 for upstate providers. 
  • Development of a blended rate cell for establishing a Managed Long Term Care (MLTC) premium for nursing home populations.  This follows considerable discussions with consumer advocates who objected to a distinct nursing home rate cell.
  • DOH will require Managed Care Organizations to adhere to the present bedhold payment policies in place (i.e., 50% payment for hospital reserve days/95% for therapeutic leaves).
  • DOH confirmed the components of the benchmark FFS rate previously announced (operating rate through 2017 pricing transition/assessment add-on/capital pass-through/universal settlement (if approved).
  • DOH anticipates issuing the 2014 nursing home rates within the next few weeks, and will then begin developing MLTC premiums soon afterward. 

NYSHFA will continue to work with the Department and closely monitor these and other policy revisions as the transition policy document is finalized, and will distribute it once DOH authorizes its release.

Director, Finance & Reimburement
518-462-4800 x36
  Stephen B. Hanse, Esq.
Vice President, Governmental Affairs
518-462-4800 x25