DOH Issues New Fiscal Intermediary Rate Structure

On July 1^st, the Department of Health (DOH) issued Managed Care Policy 19.01, which sets forth a new Fiscal Intermediary (FI) rate structure effective Sept. 1, 2019. The policy implements a new Per Member Per Month (PMPM) rate structure enacted as part of the 2019-20 State Budget for FIs serving the Consumer Directed Personal Assistance Program (CDPAP).

DOH will implement a three-tier PMPM rate structure for FI services provided to Medicaid fee-for-service (FFS) members enrolled in CDPAP. FIs will bill a separate rate code for each consumer for each month that the FI is providing service to that consumer based on the number of direct care hours authorized by the Medicaid Managed Care Plan or the Local Department of Social Services (LDSS).

PMPM reimbursement shall be as follows:                 

Under this new structure, Medicaid payment for provision of Personal Assistance and FI administration will have to be deconstructed and separately established. Currently, FIs are paid as part of the hourly reimbursement rate for personal assistance.

Managed Care Organizations (MCOs) may rely upon this tiered PMPM rate approach to reimburse FIs. Alternatively, MCOs may negotiate administrative PMPM rates with FIs pursuant to provider contracts. In either case, MCOs must continue to make timely reimbursement to FIs for the direct wage costs of personal assistants, including ensuring that contractual reimbursement meets New York State minimum wage requirements. MCO capitation rates paid by DOH will be adjusted, subject to actuarial soundness certification by the independent actuary, to reflect the change in Medicaid FFS reimbursement policy.

The policy includes terms for transition of consumers when FIs close or cease operation. Pursuant to the budget, all FIs will be required to apply for authorization by the Department. Only those chosen for authorization will be allowed to continue operation; others will have to close. The transition policy provides for written notice of FI closure to consumers, personal assistants, Managed Long Term Care (MLTC) plans, LDSSs, and the Department; processes for consumers to choose a new FI; preservation of FI choice; a process for transfer of all relevant records; managed care plan and LDSS roles in the transition; and timelines for all of the above.

Additional guidance is forthcoming on the FFS rate codes for the tiered PMPM rates and the separate FFS direct care hourly rates. DOH will also be issuing templates for various required notices.

Questions regarding transition provisions should be directed to ConsumerDirected@health.ny.gov.

Contact: Meg Everett, meverett@leadingageny.org, 518-867-8871