DOH Posts Revised Nursing Home Rates

Last Friday, the Department of Health (DOH) notified nursing homes that revised Jan. 1, 2019 rate sheets have been posted to the Health Commerce System (HCS). The revision updates the 5 percent case mix index (CMI) constraint amount shown on line 15 for those homes subject to the constraint. January 2019 rates posted on June 21^st had carried forward the July 2018 constraint in error.

The original rates will be paid in rate cycle 2184, with the revised rates for affected homes reflected in Medicaid payment cycle 2185 (check date July 8^th, release date July 24^th). Homes whose July 2018 and January 2019 rates are not constrained should see no change to their rate due to this revision (unless a facility-specific issue is being addressed).

DOH has now also posted the January 2019 Adult Day Health Care (ADHC) rate sheets to the HCS. Note that the 1.5 percent Health Care Transformation Fund increase is not reflected on the ADHC rate sheet itself but is part of the rate. A separate Excel sheet has been posted that indicates the 1.5 percent add for each program (which can also be easily calculated by multiplying the operating component by 1.5 percent).

Given that payment will be made in multiple payment cycles, we recommend that members track and validate payment and adjustment amounts. We also suggest that members review the most recently posted January 2019 rate sheets carefully to ensure that case mix, capital, and various other adjustments are correct. The Dear Administrator Letter (DAL) that accompanied the January 2019 rates is available here.

Payment Schedule:

Medicaid Payment Cycle 2183 (check date June 24^th, release date July 10^th) will reflect the Nov. 1, 2018 rate retroactive to Nov. 1, 2018. This rate is the same as the July 1, 2018 rate but includes a 1.5 percent increase to the operating rate to reflect Health Care Transformation Fund funding.

Medicaid Payment Cycle 2184 (check date July 1^st, release date July 17^th) will reflect the Jan. 1, 2019 rate retroactive to Jan. 1, 2019. The rate will carry forward the July 2018 CMI constraint adjustment amount on line 15 for homes subject to the constraint.

Medicaid Payment Cycle 2185 (check date July 8^th, release date July 24^th) will reflect the REVISED Jan. 1, 2019 rates, updating the CMI constraint amount on line 15 from the July 2018 amount to January 2019. ADHC rate adjustments will be included in this payment cycle.

Important Rate Clarifications:

Assessment Reimbursement. The assessment reimbursement listed on the benchmark rate list (available for download here) is calculated in a different way than in prior years. Instead of being the 2017 reconciled amount, the amount reflects 2018 assessment payments, possibly trended forward, divided by days. The amounts will also be reflected in fee-for-service (FFS) assessment reimbursement payments shortly, and DOH will process an adjustment retroactive to Jan. 1, 2019, although it is not yet clear in which Medicaid payment cycle. DOH has promised to provide details, which we will share with members.
Minimum Wage, 1.5 Percent, and Quality Penalty. The 2019 rates include updated minimum wage funding amounts. These are combined with the 1.5 percent increase and quality penalty adjustment (if any) on line 13. The most recently posted benchmark rate list includes separate columns showing the minimum wage, 1.5 percent, and quality penalty amounts individually.
NHQI Quality Penalty. Homes that are in the lowest quintile (i.e., fifth) in the 2018 Nursing Home Quality Initiative (NHQI) and were also in the fourth or fifth quintile in 2017 will see a 2 percent reduction to their 2019 rates. At this time, DOH has not yet updated the rate sheets with this year’s penalty amount, so the Jan. 1, 2019 rates carry forward last year’s penalty. DOH will update these amounts and make appropriate adjustments retroactive to Jan. 1, 2019 for impacted homes. Note that the 2 percent NHQI penalty is separate from the self-funded $50 million NHQI pool, which results in positive and negative adjustments that will be made as lump sums later in the year.

A few members have noted discrepancies in case mix or capital component figures. If you identify a simple error or omission, please email nfrates@health.ny.gov and copy us in. The rate DAL includes instructions for filing a formal rate appeal should that be necessary.

Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841