Nursing Home Reimbursement Update

During a meeting with LeadingAge NY and other associations, the Department of Health (DOH) provided insight on the timing of CINERGY and Advanced Training Initiative (ATI) payments and indicated that January 2022 Medicaid rates were not imminent. Highlights of the discussion are provided below.

Jan. 1, 2022 Medicaid Rates. Due to technical difficulties with importing cost report data, the customary practice of circulating capital rates for the upcoming year to providers for their review is still pending. No timeline is set for when DOH will post capital rates for review, but in previous discussions, DOH indicated their intent to offer providers a similar opportunity as in prior years to review and submit correction requests to the capital calculation. Similarly, there is not yet a time established for providers to review Minimum Data Set (MDS) data to be used in the case mix index (CMI) calculation. The CMI in the January 2022 rates will be based on MDS data from the six-month period from April 1, 2021 through Sept. 30, 2021.

One of the issues that the Department has identified as a cause for delay in importing and working with the most recent cost report data has been the use by some providers of third party proxy cost report software to complete the report. As the cost report filing due date approaches, DOH will provide additional information and request that those completing the cost report avoid using proxy software. The 2021 cost report due date is expected to be similar to prior years (i.e., July/August).

70/40 and Staffing Funding. The Department was not able to provide any additional information on the 70/40 provision, indicating that it was a moving target given the proposals to amend the requirement in the Executive Budget. Similarly, DOH had no information to share on the staffing funding that was included in last year’s budget or proposed in this year’s Executive Budget.

CINERGY and ATI Funding. The first half of the second year of Phase III CINERGY funding has been processed and will be paid in Medicaid cycle 2320, with a check release date of Feb. 23^rd. The second half is expected to be loaded into eMedNY toward the end of the State Fiscal Year (SFY). The traditional ATI distribution of $46 million is pending as the State works toward enhancing the funding through some additional ATI dollars made possible by an enhanced federal Medicaid match for home and community-based services. The additional ATI would be targeted at training nursing home staff to assist residents in transitioning back to the community. DOH estimates that ATI funding will be distributed early in SFY 2022-23. We will provide more information as soon as it is available.

MDS Audits. The Office of the Medicaid Inspector General (OMIG) reported that 60 2017 MDS audits with findings are in the re-rugging process with DOH, and that OMIG has closed 174 audits and issued 107 draft audit reports. All 2017 MDS audit reports have been issued. OMIG expects to start auditing MDS assessments related to 2018 picture dates by mid to late summer 2022.

2021 NHQI. Nursing homes should have received, or will be receiving shortly, a Dear Administrator Letter (DAL) indicating that the Nursing Home Quality Initiative (NHQI) quality measures for 2021 have been finalized. The methodology follows the same parameters as those proposed in December with one major change: the potentially avoidable hospitalization measure is removed to offset the impact of COVID-19 and the lack of hospitalization data, leaving the maximum score for 2021 at 70 points.

The 2021 NHQI payment year will be based on measures from 2020. While the structure will remain similar to previous years, five measures will be removed: four suspended due to COVID-19 impact concerns, and one eliminated permanently because it has been retired by the Centers for Medicare and Medicaid Services (CMS). The base total score of the remaining measures will be adjusted to ensure that relative weights of each domain remain the same.

The five measures that will be removed for the 2020 measurement year/2021 payment year are:

Long Stay High Risk Residents With Pressure Ulcers (five-point measure suspended for one year)
Long Stay Residents Who have Depressive Symptoms (five-point measure suspended for one year)
Long Stay Residents Who Lose Too Much Weight (five-point measure suspended for one year)
Potentially avoidable Hospitalizations (10-point measure suspended for one year)
Long Stay Residents Who Self-Report Moderate to Severe Pain (five-point measure permanently retired by CMS)

In addition, the staffing measures that rely on Payroll-Based Journal (PBJ) data will be calculated using only Quarters 2, 3, and 4 of 2020. CMS had made PBJ submissions for Quarter 1 of 2020 optional. Two five-point measures are derived from PBJ data: Staffing Hours per Resident Day and Percent of Contract Staff Used.

Two measures that were switched from quintile scoring to threshold scoring last year will continue to be scored based on thresholds for the 2020 measurement year as well. These include:

Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
Percent of Long Stay Residents with a Urinary Tract Infection

Two five-point measures suspended last year are back in the mix for the 2020 measurement year:

Percent of employees vaccinated for influenza
Timely submission of employee influenza immunization data

The timeframe of the data used in the 2021 NHQI is as follows:

MDS measures are based on Calendar Year (CY) 2020
Long-stay Resident Flu Vaccination Rates based on October 2019 – June 2020
PBJ Staffing Data based on April 2020 – December 2020 (i.e., Q2, 3, and 4)
Employee Flu Vaccination Rates based on 2020-21 Flu Season
Regionally-Adjusted Health Inspections as of April 2021
J/K/L Deficiencies awarded between July 1, 2020 and June 30, 2021 reviewed in October 2021

Please let us know if you have questions.

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