DOH Issues Guidance on FI Administrative Reimbursement
On March 11th, the Department of Health (DOH) issued guidance on how changes to Consumer Directed Personal Assistance Services (CDPAS) Fiscal Intermediary (FI) administrative cost reimbursement will be operationalized in fee-for-service (FFS) Medicaid beginning April 1, 2021. Regulatory changes to 18 NYCRR § 505.28(j) promulgated in January strip the administrative component out of the CDPAS hourly Medicaid FFS rate and reimburse administrative costs as a separately billed, per-person, per-month (PMPM) amount. The monthly administrative reimbursement for each client will fall into one of three tiers based on the number of service hours authorized for the month. Although issued as Managed Long Term Care Policy 21.02, the guidance details the FFS billing conventions of the change and provides examples for determining the appropriate tier. The policy specifies that managed care plans may, but are not required to, reimburse FIs using the tiered rate structure or, alternatively, may opt to negotiate administrative rates using a PMPM or an alternative structure with FIs.
The monthly reimbursement amounts, which are also published in the regulations, are $146 for clients with up to 159 hours per month, $384 for those authorized to receive between 160 and 479 hours of service per month, and $1,036 for individuals authorized for 480 or more hours per month. The guidance specifies that capital costs, minimum wage and workforce recruitment and retention supplements, and up to a 2 percent allowance for profit or reserves will continue to be included within the direct care hourly FFS rates and not be shifted into monthly administrative reimbursement.
Because service hour authorization may take different forms, the guidance suggests that hours be converted to a daily average based on a seven-day week, then multiplied by 31 to arrive at monthly hours. Where multiple authorizations are issued in a calendar month, the FI should determine the tier using the service authorization with the greatest number of hours and apply those hours over the entire month. The guidance document provides a number of examples for different authorization scenarios. Note that claims for CDPAS services remain unchanged and continue to be based on actual service hours delivered.
For FFS reimbursement, FIs will be able to submit FI monthly administrative claims no earlier than the first day of the month immediately following the month for which reimbursement for services is being claimed. DOH recommends that the date of service on the claim reflect the first day of the month of the service. For example, an FI billing for administrative costs for services delivered in April would submit a claim for the appropriate tier using the newly established rate codes no earlier than May 1st and list April 1st as the service date. FIs are not permitted to claim administrative reimbursement if no service hours were billed.
The same information was provided to Local Departments of Social Services as a General Information System (GIS) message (available here).
The guidance reminds plans that 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. While it is likely that DOH will use the same monthly administrative amounts in managed care rates as will be used in FFS, the key figure will be the amount by which the hourly rates are reduced to represent the administrative cost carve-out.
LeadingAge NY Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841