Medicaid Payment Adjustment Schedule
As the end of the state’s fiscal year approaches, the Department of Health (DOH) has been processing and making a number of Medicaid payment and rate adjustments. We recommend that members examine their Medicaid payments and identify and track any adjustments being made. These adjustments occasionally contain errors that require undoing or correcting, which makes tracking even more important. LeadingAge NY and other associations met with DOH last week to discuss these and other Medicaid reimbursement issues. What follows are highlights of the discussion.
CRA Reconciliation
Adjustments to Medicaid payment cycle 2057 (check release date of Feb. 8th) meant to reconcile the 2015 Cash Receipts Assessment (CRA) contained an error that resulted in incorrect adjustment amounts being loaded for all nursing homes. Because the error was identified after the payments were processed, they were reflected in cycle 2057 for most homes. To correct the issue, DOH will reverse the CRA adjustments contained in cycle 2057 in Medicaid payment cycle 2059 (check release date of Feb. 22nd). Homes that received large positive adjustments in cycle 2057 should be prepared for a lower Medicaid payment in cycle 2059. The correct 2015 CRA reconciliation adjustments will then be included in payment cycle 2061, which has a March 8th check release date.
While the correction will be done automatically without homes needing to take any action, members should monitor CRA-related adjustment amounts to ensure that the reversals in cycle 2059 match the adjustments reflected in cycle 2057. Please note that rate adjustments reflecting the updated Jan. 1, 2017 Medicaid rates are scheduled for Medicaid payment cycle 2059 as well. DOH expects to have the 2015 CRA reconciliation calculation sheets posted in early February.
Although the process described above will impact most homes, DOH will intercept Medicaid cycle 2057 payments for approximately 35 providers and issue replacement checks without the erroneous CRA adjustment amount. The Permanent Facility Identifiers (PFI) for LeadingAge NY members in this category are: 0048, 1018, 1126, 1369, 1600, 4407, and 4755.
2017 Medicaid Rate & Capital Attestations
DOH posted the Jan. 1, 2017 nursing home and ADHC Medicaid rate sheets on the Health Commerce Network on Feb. 1st. The case mix adjustment used in these rates is based on the July 2016 “picture date." Please note that if your home is receiving any minimum wage funding, the add-on amount is shown on line 13, “Misc. Per Diem Adjustments,” of the first page of the rate sheet, and the funding must be used as described in Attachment C of the Dear Administrator Letter (DAL) posted along with the rates. The DAL is available here. Although the Medicaid State Plan Amendment (SPA) authorizing rate increases to fund the minimum wage for nursing home workers is still pending with the Centers for Medicare and Medicaid Services (CMS), the state is confident that it will be approved and is incorporating the full adjustments in the Jan. 1, 2017 rates.
DOH was not able to complete their review of all of the capital attestations received. Most are incorporated, but those homes whose capital attestations DOH is still reviewing will see their DOH-calculated capital component on this rate sheet pending an update for approved attestations when all of the DOH reviews are complete. These capital updates are not likely to be made prior to April 2017. Associated rate adjustments will be reflected in Medicaid payment cycle 2059 (check release date of Feb. 22nd). Attachment F of the DAL provides instructions on accessing the rate sheets on the Health Commerce Network.
Homes may file electronic appeals to their Medicaid rate up to 120 days from the date of rate issuance (Jan. 31, 2017) as described in Appendix E of the Rate DAL. Homes whose capital rate is based on an accepted attestation will void the attestation if a capital appeal is filed.
DOH is contemplating changes to the attestation process for next year to help ensure that final rates are issued by Jan. 1st. The state intends to require all homes to attest to their capital calculation, whether they are submitting corrections or accepting the DOH calculation. Along with preparing a webinar to be held shortly to help educate providers on capital issues DOH has encountered in the attestation process, DOH intends to begin the process earlier next year, which may require an earlier cost report submission date than the July 15th date used for the last two years. DOH was amenable to suggestions to revisit an earlier initiative to streamline the cost report by eliminating unneeded schedules. Members with recommendations on streamlining the RHCF cost report are invited to submit their suggestions.
Equity Withdrawals
DOH has noted that based on their analysis of 2014 cost reports, $124 million in equity withdrawals was made by homes that failed to request DOH authorization. The requirement to seek DOH approval for such transactions is provided in a 2009 Dear Administrator Letter (DAL). While such transfers are more common in for-profit organizations, they can include certain transfers that not-for-profit homes may make, such as those from a foundation. DOH included a reminder of this requirement in Appendix G of the 2017 Rate DAL and will soon be sending all homes that seem to have made unauthorized transfers a letter outlining the home’s options. The state has not yet decided whether and what type of sanctions may apply to these violations. DOH is working on a new form, but until that work is completed, the old form should be used.
ATI Payments
Advanced Training Initiative (ATI) funding was distributed to eligible homes in Medicaid payment cycle 2056. DOH is working with provider associations to develop an evaluation of ATI-funded training programs that would support the continuation of ATI funding. Homes that have received this funding may be asked to submit requested information that would help gauge the impact of the training they have implemented. We remind members that this funding is subject to the cash receipts assessment.
Off-Site ADHC Capital
Due to regulatory concerns, the state has not reimbursed off-site Adult Day Health Care (ADHC) programs for rental costs in 2016 or 2017. DOH is discussing ways to address this issue but has not yet developed a solution. Homes that have attested to their nursing home capital will be allowed to file an appeal regarding their off-site ADHC rental reimbursement without negating their nursing home capital attestation. We are working with DOH and other policymakers to find a remedy.
Shared Savings from Refinancing
DOH continues to work on developing policies around the CMS-approved initiative to allow homes to share in the savings that accrue from mortgage refinancing. Homes whose refinancing arrangement closed on or after April 1, 2015 would be eligible to apply. After considering a number of requests, DOH has decided that the April 1, 2015 date will be firm, and refinancing arrangements completed earlier will not be eligible. Homes seeking to participate in the program will likely access the program by filing a rate appeal, and DOH envisions performing a preliminary shared savings calculation when a home requests authorization from DOH to enter into a refinancing arrangement.
Medicaid Lag
Medicaid payments are delayed by two weeks from the check date to the payment date. This “Medicaid Lag," which applies to payments from the state to Medicaid managed care plans and providers, can be waived if the entity demonstrates a serious financial need. DOH is reviewing how many nursing homes have this waiver and has requested financial information from those homes to support continuation of the lag. The state’s intent is to review eligibility for this waiver every six months and to allow it to expire for providers whose financial condition no longer warrants it.
Other Issues
DOH staff provided a brief budget update as part of the meeting which was similar to the Global Cap update. DOH has posted 2016 Nursing Home Quality Initiative (NHQI) final score sheets. There was no news on supplementing nursing home Medicaid rates by 1 percent as the SPA awaits CMS approval, there was no discussion of a timeline for removing transportation from the nursing home Medicaid rate (retroactive to April 1, 2016), and there was no news on the prospect for resolving the challenge to the NHQI to allow prior years’ adjustments to be made.
Hospital-based Homes
For most hospital-based nursing homes, the negative adjustment amount on line 14 (bed-hold related cut) on their April 1, 2013 rate sheet quadrupled when DOH issued updated April 1, 2013 rate sheets to reflect MDS audits. This was an error; the amount should NOT change from the amount shown on the previously-issued April 1, 2013 rate sheet. This adjustment was in Medicaid payment cycle 2052. DOH is processing a correction, although we are uncertain which Medicaid payment cycle will reflect this correction.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841