Nursing Home Transition Workgroup Considers Recommendations
During its Sept. 13 meeting, the DOH Nursing Home Transition Workgroup reviewed recommendations from its subcommittees on managed care for the nursing home population. Among the issues generating the most discussion were nursing home network requirements, Medicaid eligibility determinations and payments to nursing homes and managed care plans. LeadingAge New York is represented on the group and raised several issues during the meeting.
On network requirements, it was suggested that each Medicaid managed care plan would need to have contracts with at least the lesser of: (1) Thirty percent of the nursing homes in each county; or (2) Eight nursing homes per county (with the exception of Oneida County, with a 23.5 percent requirement). In addition, each plan would need contracts with at least two facilities for each specialty service (e.g., ventilator, AIDS, etc.) in those counties where they are available. The workgroup also suggested that the lock-in provision in mainstream Medicaid managed care be eliminated so that enrollees who need nursing home care will have greater choice of facilities.
In the eligibility area, several questions were raised about whether nursing homes or plans would help recipients with Medicaid conversion applications; how payments would work if someone is ineligible due to transfer of assets (in this case the plan would pay the facility while the determination is pending and then recoup the funds if the person is found ineligible); and how guardianship cases would be administered.
On the payment side, DOH clarified that if an existing contract between a managed care plan and a nursing home pays less than the fee-for-service (FFS) Medicaid rate, the contract will need to be modified to pay the facility at least the FFS rate for two years when nursing home managed care enrollment becomes mandatory during 2014. LeadingAge NY and other workgroup members suggested the state consider extending the two-year rate protection for an additional period and clarifying how the transition would work for the capital component and any universal settlement of nursing home rate appeals and litigation. DOH also discussed efforts underway with LeadingAge NY and other groups to seek permission from CMS to have the state or its designee take over collection of resident net available monthly income (NAMI), relieving facilities and plans of this responsibility.
Other areas discussed during the meeting included credentialing requirements, quality measures and shared savings opportunities. LeadingAge NY’s Nursing Home Managed Care Workgroup will be meeting again soon to discuss these issues and make recommendations on future strategy.
Under DOH’s latest proposal, persons who are permanently placed and Medicaid-eligible in a nursing home before to Jan. 1, 2014 in the FIDA region (NYC, Long Island and Westchester) and April 1, 2014 elsewhere would remain in FFS for the duration of their nursing home stay (unless they voluntarily enroll in FIDA or are passively enrolled in FIDA and do not opt out), but any individuals who are newly permanently placed and/or become Medicaid eligible after those dates would be required to enroll/remain in an MLTC plan (if dual eligible) or mainstream plan (if Medicaid-only eligible). The nursing home would then be paid by the plan directly for services to those residents. Voluntary FIDA enrollment would begin on Oct. 1, 2014 in the FIDA region, with passive enrollment starting Jan. 1, 2015.
Contact: Dan Heim, dheim@leadingageny.org, 518-867-8866