DOH Rate-Setting Update

Carl J. Pucci in Finance & Reimbursement

Although the November DOH Rate-Setting Briefing was canceled, NYSHFA was provided an update on the following issues:

Case Mix

DOH issued the January 2014 CMI adjusted rates (effective 7/1/14) in early November.  Members should carefully note any changes to their “Facility Case Mix Adjustment” (line 4) and corresponding changes to their “Adjustment to Cap Case Mix” (line 15).  Any questions should be directed to

Quality Pool

The 2013 Quality Pool rates are at EMEDNY and are expected to be paid by year-end.  DOH is expecting to release the 2014 Quality Pool data and respective DAL shortly.

CR Assessment

The 2012 CR Assessment Reconciliation is currently at DOB and should reach EMEDNY in early January.  Additional review time by DOH was necessary, as the overall statewide impact to providers was negative.  DOH will be updating the assessment add-on per diem from 2010 to 2012 going forward.

OMIG/Case Mix Audits

The 2012 audits which affect the July 2012 and January 2013 rates are at DOB and are expected to reach EMEDNY in January 2015.  Providers with “clean” audits should be receiving OMIG notification letters.  As requested, DOH will be meeting in early January with NYSHFA and other statewide association clinicians to discuss OMIG findings, as well as member concerns regarding the MDS.

2015 Final Rates

The final 1/1/15 rates are expected to be issued in early February 2015, and will include the updated July 2014 CMI, as well as updated capital components that were corrected during the hotline period.

Benchmark Rates

NYSHFA worked with DOH to correct the July 2014 benchmark rates to include the Quality Pool adjustment in the overall total per diem.  (It had been excluded since it was not considered part of the baseline FFS rate.)  DOH agreed to adjust the 7/14 benchmark rate file currently posted on its website, as well as to add historical benchmark rate files (i.e. 1/1/14) for reference purposes.  We will notify members once the benchmark rates have been corrected.

Managed Care

DOH has not yet received CMS approval of the MLTC transition, still slated for 1/1/15.

NYSHFA continues to advocate for various billing, payment and receivable protections as part of the Transition Billing Workgroup.  The Workgroup reviewed MCO summary claims data and continues to focus on a standardized billing document going forward.

Capital Workgroup

NYSHFA and other statewide associations are working with DOH on Article VII Budget language to introduce capital financing shared savings, and retention of savings related to energy initiatives (a product of the Energy Sub-committee Workgroup).  We will keep members appraised during the upcoming Executive Budget process.

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


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