DOH Rate-Setting Update

Carl J. Pucci in Finance & Reimbursement

DOH held its monthly rate-setting briefing earlier this week.  The agenda items discussed included the following:

Rate Packages

  • 2012 Case Mix Audited Rates are at EMEDNY for processing.  They are scheduled for cycle 1999 (check date 12/14/15, with check release 12/30/15).  The overall statewide effect of the 5% cap release is approximately $14 million to providers.
  • 2013 Case Mix Audited Rates are at rate-setting prior to final review by DOB.  Expect processing during 1st Quarter 2016.  (Affects 7/1/13 and 1/1/14 rates).
  • 2016 Rates – will be revised to reflect the January 2015 CMI, as well as adjusted Capital, and are expected to be issued in mid-January.

MDS Collection

DOH is working to complete the July 2015 MDS collection, as there are still 40 or so missing facilities.  Members are urged to submit any missing MDS no later than Friday, 12/18/15 in order to avoid default rate status.

DOH also reminds providers that Medicaid Managed Care residents still need to have their MDS submitted to CMS.

Advanced Training Initiative (ATI)

All but five facilities (out of 227 eligible) have elected to participate in the ATI initiative.  DOH is working on a rate package, retroactive to 4/1/15 to pay the State Share of the funding (approximately $23M).  The rates will be forwarded to DOB next week.  The remaining $23M of the funding will be released once CMS approves the State Plan Amendment.  Notification letters have been sent to facilities.

Universal Settlement (US)

The due date for submission of the Universal Settlement agreement and appropriate release is this Saturday, 12/12/15.  The Associations have compiled an FAQ and NYSHFA has provided a new/old owner guidance for members as they complete the required US documents. The Associations continue to work with members on Appendix C (excluded appeals) revisions, as well as ensuring that the US documents reach all affected provider contacts.

Capital Streamlining

DOH reported that the Capital Attestation Initiative was successful, with over 250 attestations submitted, and an initial approval rate of 80%.  DOH is working with facilities whose attestations have been denied in an attempt to resolve as many as possible prior to the 2016 Capital Rate revisions in mid-January.

Quality Pool/1% Restoration

Both of these State Plan Amendments are being held by CMS until DOH completes the 2014 Upper Payment Limit (UPL) calculations.  DOH did not give any further timelines at this point.


CMS is reviewing the DOH white paper, and has set this as a separate agenda item as they continue to raise questions related to the State’s proposed takeover of the NAMI process.

Energy Initiative

As previously reported, DOH has selected a pilot list of 30 facilities to participate in the energy audits.  DOH is meeting with NYSERDA and will be offering a webinar within the next few weeks to provide detailed information.

Shared Savings/Mortgage Refi

CMS has raised further questions regarding this initiative as discussions continue with DOH.

Assisted Living Program (ALP) Workgroup

NYSHFA will participate in the initial ALP Workgroup, set for next week.  Agenda items will be submitted in advance by NYSHFA/NYSCAL in an effort to address various issues.

NYSHFA will continue to monitor these issues and update members accordingly.


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