State to Release Nursing Home Funding

The case mix reflected in a nursing home's July 2012 Medicaid rate (based on January 2012 roster submissions) is currently constrained to be within 5 percent of the CMI used in the January 2012 rates. The state will remove this constraint and make the required rate adjustments this summer. Homes whose CMI was not constrained will see no change.

All homes subject to the constraint should receive updated rate sheets. Payment adjustments should be contained in the July 29, 2013 Medicaid check which has an Aug. 14 release date. 

OMIG will continue to audit the January 2012 roster submission-related MDS assessments for those homes whose CMI grew by five percent or more from January 2011 to January 2012. They have also selected 250 homes for audit of July 2012 roster submission-related MDS assessments. DOH indicated that OMIG will update their audit protocol beginning with audits of the July 2012 census submission to include review of the BMI, DEMENTIA and PAYOR responses in addition to ensuring support for all other responses which impact the case mix calculation.

The state’s goal is to have all 2012 MDS audits completed by the end of 2013.

We continue to urge DOH to provide guidance and educational resources to providers regarding MDS completion expectations, especially if they are contemplating expanding the scope of the audits in the future. The text of the DOH message is copied below.

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

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Dear Administrator:

DOH will be releasing rate adjustments reflecting the full case mix (i.e., over and above the +/-5% previously reflected in rates) associated with the January 2012 census collection, effective with the July 2012 rates. DOH anticipates that internal processing of these rates will be completed near the end of July and will be paid in checks dated July 29, 2013 with a release date of August 14, 2013.

OMIG and DOH have discussed the findings of the first MDS audit sample of 79 facilities:
· 79 facilities were reviewed

· 58 of the facilities in the sample had no decrease in CMI resulting from the audits

· 21 of the facilities in the sample had decreased CMI resulting from the audits

· Some facilities had CMI decreases of over 10%

· Overall in the sample the decreases did not result in significant rate changes

In agreement with OMIG, DOH has determined that the case mix associated with the January 2012 collection will be paid in full.

In accordance with 10 NYCRR 86-2.40(m)(10) additional audits of the January 2012 census will continue and DOH/OMIG will evaluate the status of the July 2012 census to determine subsequent case mix payments and audits.

· 250 facilities will be audited with each census submission

· For the January 2012, 171 facilities remain to be audited. OMIG is in the process of sending engagement letters to facilities.

· Be advised that OMIG is combining the remaining audits of the January 2012 census and July 2012 census to process the audits more quickly

· The remaining 171 January 2012 facilities will also have their July 2012 census submission audited

· An additional 79 facilities will be reviewed for July 2012.

OMIG will also update their audit protocol beginning with audit of the July 2012 census submission. OMIG will be reviewing the BMI, DEMENTIA and PAYOR responses in addition to ensuring support for all other responses which impact the case mix calculation.

To ensure that all of the 2012 audits are processed before the end of 2013, OMIG will be hiring nurses to augment their staff. All nurses on the audit teams will be RNs, with MDS 3.0 training and will have received OMIG audit training. Working with the Associations, DOH and OMIG are also planning to make educational resources on MDS/case mix available to facilities in the future.

Thank you.