DOH Clarifies Nursing Home Transition to Managed Care
The Nursing Home Transition work group convened by the Department of Health (DOH) met this week to finalize draft policies that will govern the transition of the nursing home benefit and population into managed care. Subject to federal approval, Medicaid enrollees in downstate areas in need of permanent care in a nursing home will be required to join a managed care plan starting in March of 2014. In upstate counties, this requirement will be phased-in starting in September 2014. Individuals who are already permanent nursing home residents at the time that the requirement goes into effect in their county will not be required to enroll into a plan and may continue in fee-for-service Medicaid. Slides outlining transition policies as of December 2013 are available here. Significant changes or clarifications to the policy made since that time include:
- Managed Care Organizations (MCOs) will be required to pay a nursing home provider the current fee-for-service rate for three years, instead of the two years originally proposed. However, a plan and provider may negotiate an alternative rate acceptable to both parties. The three year period will start in March 2014 downstate and on Jan. 1, 2015 upstate. DOH will reassess whether there is a need for a longer transition after one year. This provision is included in the governor’s 2014-15 state budget proposal, which also specifies that the fee-for-service rate requirement does not apply to short-term Medicaid residents.
- Contracts between providers and MCOs will be required to include due process rights for the provider and must allow the provider to remedy any identified problems prior to imposition of penalties or termination of the agreement. If an agreement should be terminated for reasons other than imminent patient harm or a finding of fraud, the MCO must continue the member’s placement in the nursing home as an out of network placement and pay Medicaid fee-for-service rates.
- While a separate rate cell will be used for enrollees of mainstream Medicaid Managed Care plans requiring permanent nursing home placement, a blended rate cell will be used for this population when the Managed Long Term Care (MLTC) plan premium is calculated. This change was made to allow the proposal to go forward.
- MCOs will be required to make bed hold payments for Medicaid residents based on the same rules (i.e., day limitations and 95 percent occupancy threshold) and rates (50 percent of Medicaid rate for hospitalization bed hold, 95 percent for therapeutic leave bed hold) governing fee-for-service Medicaid bed hold.
- Provisions included in the previous version of the policy document that would have established a mechanism to address MCO cost anomalies of providing nursing home care to their enrollees have been removed. Risk mitigation related to nursing home placements as well as a separate nursing home rate cell for MLTC plans were adamantly opposed by consumer advocates and ultimately removed. DOH has promised to closely monitor the adequacy of the blended rate.
Network adequacy standards remain the same: MCOs are required to contract with eight plans in Kings, Queens, Bronx, Suffolk, Nassau, Westchester, Erie and Monroe counties; five in New York and Richmond counties; four in Oneida, Dutchess, Onondaga and Albany counties; three in Broome, Niagara, Orange, Rockland, Rensselaer, Chautauqua, Schenectady and Ulster counties; and two in all other counties (where available).
DOH expects to issue 2014 nursing home Medicaid rates in January and publish managed care premiums in February. Plans will receive nursing home rates by component (including the cash receipts assessment add-on) with a break-out of individual non-comparable ancillary cost center costs to facilitate negotiations between plans and providers. Plans will be required to pass-through the capital component and any universal settlement payments to the facilities. DOH estimates that there are approximately 8,400 Medicaid nursing home permanent placements annually in the downstate area (NYC, Long Island and Westchester) that will be covered by the new requirement and roughly half that many in the rest of the state.
LeadingAge New York continues to work with DOH to address details of the transition, and as soon as the policy document is final we will share it with members.
Contact: Dan Heim, dheim@leadingageny.org, 518-867-8866 or Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841