DOH Rate-Setting Update

Carl J. Pucci in Finance & Reimbursement

DOH conducted its monthly rate-setting briefing earlier this week. The topics discussed include the following:


Quality Pool

The 2013 Quality Pool rates are at DOB and are expected to be processed by EMEDNY within the next few weeks.

CR Assessment Reconciliation

The 2012 CR Assessment Reconciliation is under review at DOB presently.  The statewide impact to providers is a negative $20M, due to differing cost basis used for the calculation, as well as the 2 year gap vs. the payment add-on (2010).  DOH is exploring updating the assessment add-on to 2012 to minimize future reconciliation impacts to providers.  The Associations stressed the need for more timely reconciliation, and continue to seek clarification of the reconciliation process going forward into a Managed Care environment.

2015 Initial Rates

The final 1/1/15 rates will include updates reflecting the July 2014 Case Mix, as well as all capital hotline period adjustments.  The rates are expected to go to DOB next week, and DOH has requested DOB expedite the rate package to EMEDNY for processing in February.

Case Mix Audits

The 2012 MDS audits which affect the July 2012 and January 2013 rates will go to DOB by the end of January.  The expected statewide impact to providers upon release of the 5% CMI cap is a positive $14M.  The benchmark rates will be updated once the audit rates are released.

NYSHFA clinicians met with DOH recently to clarify current MDS audit issues (see member mailing 1/8/15).  Instructions and clarification on completing the MDS will be implemented by 4/1/15 in time to affect the July 2015 census roster.

The 2013 OMIG audits are nearing completion and a quicker turnaround in subsequent rate processing is expected from DOH due to increased MDS training and education, as well as the experience gained via the 2012 initial audit process.

Capital Workgroup

The update centered on two initiatives presently underway as part of the 2015/16 Executive Budget process.

  • Capital Rate Setting – enables facilities to assume ownership and responsibility of their own capital per diem through process review and edits prior to rate processing.  Providers would submit and certify appropriate revisions to their initial capital component and thereby reduce capital appeals and/or litigation.
  • Energy Efficiency/Disaster Preparedness – continued DOH/NYSERDA/Associations collaborations to develop public/private financing options with the goal of reducing energy costs and providing shared savings with the LTC industry.  The 2015/16 Budget is expected to include approximately $2M in funding with an additional $1M supplement from NYSERDA.

DOH is seeking Association input with respect to both initiatives.  NYSHFA’s Payment for Services Committee will continue to review and provide input with respect to both capital related initiatives.

Managed Care

The transition date for Managed Long Term Care is still expected to commence on 2/1/15.  DOH has scheduled a meeting with all stakeholders tomorrow afternoon (1/16/15), as well as a webinar tentatively scheduled for 1/22/15.  Complete details will be provided in a Managed Care update following the briefing.

NYSHFA will keep members informed on these and other pertinent issues as they develop.


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