DOH Rate-Setting Briefing

Carl J. Pucci in Finance & Reimbursement

DOH held its monthly Rate-setting briefing earlier this week which included the following updates:

2015 Initial Rates

The initial 1/1/15 operating and capital rates were posted on 10/31/14 to the HCS.  (See member mailing 10/31/14).  Providers have until 12/1/14 to notify DOH of any rate discrepancies.  NYSHFA requested a facility-specific comparison of the 2015 vs. 2014 rates to monitor significant rate fluctuations and assist members accordingly during the “hotline” period.  

2015 Final Rates

The 1/1/15 Final Rates (with hotline corrections) will be published in January and will include the July 2014 CMI adjustments.  These rates will also constitute the initial 2015 benchmark rates for Medicaid Managed Long-Term Care going forward.

Case Mix

The January 2014 CMI adjustments (affecting the 7/1/14 rates) will be sent to EMEDNY on 11/7/14.  Payment of these rates should be expected in approximately 30 days.  Once a specific Medicaid payment cycle number is known, we will alert members.

Quality Pool

As previously announced, CMS has approved the 2013 Quality Pool.  These rates, retroactive to 1/1/13, are expected to be sent to EMEDNY by 11/30/14 (with payments again expected 30 days later).  DOH will send a blast e-mail within the next few weeks which will contain the 2014 Quality Pool results, as well as the related DAL.  The 2014 Quality Pool is still subject to CMS SPA approval.

CR Assessment

The 2012 cash receipts assessment is slated to go to DOB by 11/30/14, and to EMEDNY by mid-December.  DOH noted that the overall statewide impact of the 2012 assessment is a negative $11M (vs a positive $16M in 2011).  DOH also noted that the assessment add-on per deim being paid to providers will be updated to reflect 2012 expenditures (vs. 2010 currently).

OMIG Audits

The 2012 audits which affect the July 2012 and January 2013 rates have been finalized.  Providers with “clean” audits should be receiving audit closeout letters from OMIG, and the corresponding 5% CMI cap should be released for those affected.

The 2013 audits are approximately 70% complete, with the downstate area presently being scheduled for audit.  NYSHFA and the other associations again have requested that OMIG meet with our respective association clinicians to review the most common MDS coding adjustments in an effort to communicate and educate our members going forward.  In addition, the school of Public Health will be conducting MDS training sessions in early December and early January.  (Further information to follow.)

Capital Restructuring

DOH provided an update on the $1.2B Capital Restructuring Project (see member mailing 10/30/14).  They noted that both DSRIP and non-DSRIP related applications will be accepted and further information will be presented at the upcoming applicant conference on 11/21/14.  The request for applications will be released on 11/14/14, with applications due back by 12/16/14.

Managed Care

NYSHFA is actively participating in the Transition Billing Cash Flow Workgroup, which is meeting bi-weekly to discuss various billing, payment and receivable related issues in advance of the pending 1/1/15 transition to Medicaid Managed Long-Term Care.  We have provided specific billing concerns that members presently are experiencing with MCO’s in an effort to minimize any cash flow issues that may arise with the transition to Managed Long-Term Care.

2% Restoration

The 2% Restoration of the budget cut is still pending CMS SPA approval.  The specific payment methodology related to the restoration has not yet been presented by DOH.

NYSHFA will continue to monitor thee issues and keep members informed as they develop.


Carl J. Pucci
Director, Finance & Reimbursement
518-462-4800 x36