Nursing Home Reimbursement Update
(March 18, 2025) The end of the State’s fiscal year often results in a flurry of activity regarding outstanding nursing home Medicaid payments. While the Department of Health (DOH) is working on a number of issues, it seems that no payment adjustments are imminent other than the 2 percent supplemental payments in Medicaid cycle 2481 (check release date of March 26th). The 2024-25 Advanced Training Initiative (ATI) funding for eligible homes was in Medicaid cycle 2480 (released during the week starting March 17th). Status updates for other outstanding payments are outlined below.
2023 Nursing Home Quality Initiative (NHQI). DOH has finalized and published 2023 NHQI quintile rankings on its website. Detailed scores are available for download on the Health Data NY site. The associated payment adjustments are moving through executive review, although no date for their release has been established. Payment adjustments will be positive for those in the top two quintiles and negative for those in the bottom two quintiles. Those in the third quintile will see a minor positive adjustment. Homes scoring in the best quintile should expect a net positive adjustment approximating 1.2 percent of their annual Medicaid revenue; those in the second quintile should expect a bump of roughly 0.8 percent. Providers in the bottom two quintiles will see a negative adjustment approximating 0.8 percent of their Medicaid revenue.
2025 Initial Medicaid Rates. The 2025 Medicaid rates, which primarily will update the capital component given the current case mix freeze, are entering executive review. There is no projected release date.
2023 Cash Receipts Assessment (CRA) Reconciliation. These calculations have not started, but DOH expects to begin them soon. That suggests that the associated payment adjustments are several months away, at minimum. Based on specific facility circumstances, these adjustments may be positive for some, negative for others.
2024 Capital Appeals. DOH anticipates beginning work on these shortly.
Outstanding State Plan Amendments (SPAs). The communications pause imposed by the Trump administration means that discussions with the Centers for Medicare and Medicaid Services (CMS) regarding the State’s outstanding SPAs have been on hold. DOH is prepared to resume discussions. The outstanding SPAs include the federal share of the nursing home funding enacted in the 2024-25 State Budget (State share paid in mid-October, federal share of $6.77 per billed 2022 fee-for-service Medicaid day awaiting CMS approval); 2024-25 Intergovernmental Transfer (IGT) payments for county- and city-operated nursing homes ($212 million in 2023-24, comparable amount expected for 2024-25); and 2024-25 CINERGY payments for participating providers (State share paid in mid-October, $15 million federal share awaiting CMS approval).
Case Mix Freeze. DOH is working on a formal communication regarding the case mix methodology work that the State, along with its contracted firm, Myers and Stauffer, have been engaged in. The State continues to pledge that a workgroup will be established and that more information is forthcoming. DOH is not willing to comment at this time whether implementation of the new methodology is on schedule for late 2025 as projected.
Staffing Penalties. The unit charged with enforcing State staffing requirements continues to indicate that they will share more information when it becomes available. DOH had originally suggested that staffing penalty amounts associated with the initial three quarters of staffing requirement enforcement (i.e., Q2, Q3, Q4 of Calendar Year (CY) 2022) would be posted on the DOH website in January.
We will keep members informed regarding developments on any of these outstanding funding issues and ask that members keep us posted of any audit (e.g., Payroll-Based Journal (PBJ), Medicaid rate, worker bonus) or penalty (e.g., staffing, personal protective equipment (PPE)) activity that they encounter.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841