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Unformatted text preview: Complete Listing of all 4,057 NYS Medicad Redesign Team Proposals as of February 23, 2011 # Author Proposal 1 DOH Increase health facility cash assessment percentages (additional revenue to fiscal plan) for nursing home and home care services. These increases are not Medicaid reimbursable. 2 DOH 3 DOH 4 DOH This proposal will control personal care utilization and will transition personal care recipients to Managed Long Term Care by imposing provider-specific aggregate annual per patient spending caps and limiting the personal care benefit to no more than 240 hours per month in areas of the State where Managed Care is available (i.e., New York City in 2011-12; New York City, Westchester, Nassau and Suffolk in 2012-13; New Yorkareas Stateof designated are to pay an assessment cash operating receipts on atomonthly basis under the Health Facility Cash Assessment Program (HFCAP). the and other the State providers thereafter). A required State administered pool will beonavailable to provide funding work with HRA in New York City otherReceipts local service districts in the out years) toIncreasing provide information Imposes a uniform both Medicaid and private payers; eliminates hospital physician surcharge; provides additional State(and revenue administrative HFCAP wouldsurcharge result in aforsignificant revenue streamto for the State. Underbased federal regulations states may increase tax collections from and 5.5%clarifies (of totalother patient revenues) tocomplexities. 6% effective October 1, and fundsrates to smoothly transition high needadditional personal care recipients Managed Care. 2011. The impact of this assessment increase is outlined in the attached chart. Eliminate the statutory provision for trend factor (inflation factor) adjustments across Hospital Inpatient and Outpatient, Nursing Home, Home Care, and Personal Care Services. 5 DOH 6 DOH, Anonymous 7 DOH 8 DOH 9 DOH 10 Senate Medicaid Task Force 11 13 GNYHA; CNYHSA;Onondaga County;NYS Catholic Conference; MRT DOH member Jeffrey Sachs;NY State Health Plan Association;Coalition of NY State Public Health Plans Eastern Suffolk Boces 14 DOH 15 NYSCHP;DOH;Blossom View Nursing Home;PSSNY;NYSHFA;NYSCAL;Sc DOH ott C. Amrhein;CLLC; Robert J. Murphy - NY State Health Facilities DOH Association;Island Nursing and Rehab Ctr; Effie Batis, Southern New York Association; Russ of Bayberry MRT MemberLeonard (Eli Feldman, Nursing HomeJewish and Aaron Manor Metropolitan Health System), Nursing and Rehab Center; Ron Web, Zito of HANYS, NYSFHA, NYSCAL, DOH Our Lady ofDSS; PeaceJamaica NursingHosp. Care Suffolk Co. Residence;MRTCo., Member (Steve NH;Onondaga HANYs; Website DOH Acquario NYSAC); HANYs; NACDS; [email protected] 2- Website Gregory Blass (SuffolkJoan Co DSS anonymous, OPWDD; Travan; Commissioner);MRT Member Dr. Onondaga County; Senate Medicaid Nirav Shah Reform Task Force, Senior Alliance of Greater Rochester, Richard Herrick, Genesee Health Facilities, Anonymous, NAMI 12 16 17 18 19 20 The Health Care Reform Act (HCRA) imposes a surcharge at varying percentage rates on revenue received for inpatient and outpatient services of NYS general hospitals, and services of Diagnostic and Treatment Total Personal Care expenditures incare 2009 were $2.2 billion. Approximately 80% or to $ 1.76 billion is attributable York City. Despite a decline the number(CLAs) of personal care insured recipients served from To control utilization andwould reduce the proposal will transition long-term CHHA patients Managed Long Term Caretoby implementing: Centers (DTCs) thatMedicaid provide comprehensive ambulatory surgical services. Additionally, certain payers are required toNew remit to the State “covered lives in assessments” for each individual or None of 2009, these increases becosts, reimbursable byorMedicaid. 2003 to spending per recipient over this same period increased dramatically, or by almost 40 percent. family. These surcharges and CLAs, in combination with other HCRA receipts, generate over $5.0 billion annually. The monies generated are used to fund various state health care initiatives, including Medicaid An annual evaluation will be conducted by the Department (in conjunction with the budget process) to determine if reinstating the trend for the given year is warranted. The trend factor is used to inflate rates from expenses. Reduce the profit component included in the costs, plan rates frometc. 3% The to 1% for the Medicaid anda Family Health managed care programs. year to year to allow for increasing provider salaries, providers will receive trend factor forPlus 1/1/2011 - 3/31/2011 based on the current statuory provision. •Note,Provider-specific aggregate annual per-patient spending capshospital for Certified Home Agencyproposed (CHHA)was services (effectivethe April 1, 2011). the increase to the cash assessment percentage for inpatient thatHealth was initially rescinded, proposal implement Streamlining for hospitals been advanced, and This proposal eliminates the PC benefit for persons are notthe NHlevel eligible. Although personal care services are authorized by a who physician, of services service provided is determined by the local districtas (i.e., New YorktoCity HRA or HCRA local county Department of Socialhas Services). The current there is insufficient room under the provider tax cap to enact both proposals. Medicaid rate setting methodology for providers outside New York City establishes provider-specific, fee-for-service rates. The rates are based upon a rolling cost base which is updated annually (i.e., 2010 rates • a result Anlaw Episodic Pricing System which is similar current Medicare Payment system Aprilcontained 1, 2012). Pricing System will remain in all (e.g. short-term CHHA patients Federal regulations require provider taxes toreaching be “broad meaning they must apply to (effective allrequirement non-federal patient services revenue all providers within a provider taxfor Inpatient hospital As ofand this change, the phase-in schedule forto thebased”, 12.5%Prospective maximum contingent reserve inThe PartEpisodic 98 of theof NYCRR will be modified to place apply aclass 7.25% contingent reserve are based 2008 reported costs). (those that are to require less than 120rates days care).aswe Reduce theupon projected increase to Managed Care byof 1.7% ofdo 4/1/2011, byone reducing the trend byreserve 1.7%. requirements services). NYS does not comply with this requirement because not apply HCRA tofactor all the inpatient and outpatient hospitals. For example, HCRAnet surcharges do not to State requirement onanticipated net premium income from Medicaid and Family Health Plus for year.surcharges (Note: contingent are revenue deemed of to all be met if the managed care plan's worth equals or apply exceeds the Operated Psychiatric Hospitals. Federal law and regulations alsofor require provider taxes to requirement be “uniform”, meaning the rate of taxation cannot vary among providers in lines a provider tax class (e.g. outpatient services). contingent reserve requirement.) The (PCSP) existing phase-in schedule the contingent reserve would continue to apply to net premium income from all other of business. The Personal Care Services Program expends over $2 billion annually and provides services to approximately 74,000 individuals statewide. The PCS program, unlike HCBS Medicaid waivers, does not NYS proposal does not will comply with this requirement becauseTargeted HCRA surcharges are imposed at differential rates.that The surcharge is 7.04% while the private payor surcharge is 9.63%. Had the State not secured a This eliminate Medicaid coverage Case services Management Services for recipients areMedicaid in Medicaid Managed Care Plans. have a requirement thatthat individuals must be NH for eligible to access through the program. NYS-only federal law makes HCRA permissible (Pub. L 105-33 Section 4722(c)), often referred to as the “D'Amato Provision”, it would have suffered a Medicaid disallowance equal to 50 percent of total Since 1996, the New York City (NYC) personal care program has operated under a regulatory exemption to the cost based methodology. Under the exemption, HRA sets personal rates, are subject The proposal will immediately address significant growth in utilization. Total paid CHHA claims in New York State have increased from $760 million in 2003 NYC to $1.35 billion in 2009. care More thanwhich $1.2 billion of HCRA receipts. Analysis offunding a sample ofin individuals enrolled in the program inper NYC indicates 23% ofmarketing those individuals sampled not meet theBudget. NH standard used by managed long term care (MLTC) plans for to a2009 city-wide weighted average maximum price. The rates are monitored and approved by the Department and the Division of the Eliminate included in Medicaid Family Health Plus premiums forfrom direct of Medicaid recipients for Care.eligibility the spending was New York City,and where paid claims patient grew $11,867 in 2003 to $23,253 inwould 2009 – aManaged 96% increase per patient. admission into that program. These individuals accounted for 11.8% of the PC costs for the cohort. Extrapolation of these findings indicate that approximately 18,000 individuals participating in the PCS program Comprehensive Medicaid Case Management (CMCM), also known as Targeted Case Management (TCM) was authorized by Congress under the COBRA act of 1985. According to the Centers for Medicare and in NYC are not NH eligible. Move the Services NYS Medicaid Pharmacy underconsists the management Medicaid Managed Care to leverage clinicalsocial, and fiscal benefits. and other services. 'Targeted' case management services are those Medicaid definition, "Case program management of servicesofwhich help beneficiaries gain access toadditional needed medical, educational, Under the “D’Amato Provision” HCRA is effectively grandfathered as long as the State does not change its structure. At this time, however, the State doesseparate wish to TCM make programs. changes toFederal HCRA to with certain aimed specifically at special groups of enrollees such as those with developmental disabilities or chronic mental illness." New York State currently anddeal State Medicaid Personal care rates are not adjusted for acuity andthe there issome no to in control amount level of services authorized or provided. As of October, 2010 thepayors, penetration ratepatient of Medicaid recipients enrolled managed carewithout wasorand 84% ( 77% upstate and 88% NYC). In 12 the based early implementation of negating the program, it was important to Although CHHA services are authorized byeligible athe physician, level of incentive services provided is the open-ended is statewide determined by the CHHA provider. The has current Medicaid rate setting methodology established providerissues that have vexed providers and Department for time. The way to do this putting the system at risk is to make HCRA broad and uniform, thus the need for the policy and regulations dorates. notfrom permit recipients tobringing receive TCM inwhich more than one1.2%, TCM the same time period. Therefore, Medicaid restricts recipients receiving TCM services to one TCM Reduce IME teaching toto3.0%, it closer to base empirical value of &program providing fiscal plan relief while redirecting funds to health home (18M 80M 108M 13/14). allow plans the ability factor to market order increase thealevel ofservices enrollment intomanaged care since many counties were voluntary. At this time, the program isincluding mature, and those persons not enrolled are generally specific, fee-for-service Thein4.2% rates are based upon rolling cost isuniform updated annually (e.g.,for 2010 rates are based upon 2008 reported costs), and includes no11/12, incentive to12/13, control costs or achieve “D’Amato Provision. It is proposed that HCRA surcharge rates be flattened a 8.3% and applied to all inpatient and outpatient services revenue, that of state operate psychiatric hospitals. provider atexcluded any given time.theManaged care recipients whopatient qualify for TCM are presently to receive both TCM services as well as have their carethey managed coordinated by their managed care plan. exempt from program or reside inHCRA voluntary counties. Marketing arepermitted largely spent by health plans to attract members of other do applying notand focus theuntaxed uninsured. In care addition, efficiencies. The rateProgram methodology is not rationalized by acuity and there iscosts no incentive torevenue control amount or level of services Doing soorwill generate $25 million ofprescription additional revenue (an $223m of HCRA asthe awould result of increasing the Medicaid surcharge rate and iton toenrolling previously revenue, offset The NYS Medicaid covers drugs dispensed by additional pharmacies under the Medicaid Pharmacy fee-for-service program forprovided. nearly allplans; Medicaid beneficiaries, including Medicaid managed This may result in duplicative case management services. If this proposal is adopted, managed care enrollees be prohibited from receiving TCM services since coordination and referral to medically by March 2011, State will only have 7tonon mandatory counties whereFederal enrollment in managed care remains an option. Recipients in mandatory counties must enroll orhealth be increase auto-assigned into includes a managed carelives plan Increase Federal Medicaid Funding by determining actual costs incurred by school districts and counties providing Preschool/School Supportive Health by a decrease of the $198m attributable to lowering the private payor surcharge rate).rebates Importantly, the $198m private payor windfall could be recovered by Services the State(SSHSP). through an to private payor covered (MMC) enrollees. This has allowed NYS take advantage of available on prescription drugs, thereby lowering their net cost. However, recently passed care reform law necessary services will be provided by the managed care plan. To control escalating per patient costs and transition all personal care patients, areas oftothe State where ManagedbyCare is available (i.e.,care Newplans. York City in 2011-12; New York City, Westchester, (MCP), which greatly reduces the needfor forpersonal marketing. Only aPlan few states, including New Jersey, continue allow direct marketing Medicaid managed assessments, with $100 million benefiting the Statecare Financial and the rest funding the NIF. in equalization provisions that give Medicaid managed care plans the same rebates as the fee-for-service program. A number of recent reports have indicated that States can achieve significant savings in pharmacy Hospitals that have residents in an Graduate Medical Education program Nassau and Suffolk in 2012-13; andapproved other areas of the State thereafter) this(GME) proposal would:receive additional payments for both Fee-For-Service (FFS) and Medicaid Managed Care (MMC) to reflect the higher expenditures by improving management of the to pharmacy benefit with toolsThere widely insurance. can be done by including both prescription and over-the-counter medications in the Eliminate "return on" and "return of" equity and residual reimbursement provided in in thecommercial capital nursing home rate forThis proprietary nursing homes. patient carethecosts of teaching hospitals relative non-teaching hospitals. areused two components to health Graduate Medical Education costs: Direct Medical and Indirect Medical Education PROVIDER SPENDING LIMITS (Effective April 1, 2011): The provider spending limits would be based on a weighted average of the provider’s average Education claims per (DME) patient during the 2009 base period and (IME). the benefit package provided by managed care plans for Medicaid beneficiaries. EachPreschool/School component updated as part ofsame the Hospital Rate as of 12/1/09: statewide average has for been all CHHAs during the period. The limit Reimbursement would be adjusted forReform the provider’s Case Mix and regionalby differences in labor costs. Case Mix would be based on a New York26, State The Supportive Health Services ProgramInpatient (collectively “SSHSP”) State Plan Amendment (#09-61) wasfor approved the Centers for Medicare and Medicaid Services (CMS) on April 2010, Consolidates pharmacy fee-for-service proposals into oneinthe reform includes initiatives thatthe optimize rebate opportunities, reduce waste, rationalize coverage and reimbursement, or remove Medicaid Grouper which was developed Department conjunction with outside (ABT Associates) andshould presented tosurcharges the Home Care Work Group. Payments would later be reconciled using retroactive to all September 1, 2009. Reimbursement rates were benchmarked atwhich 75% theconsultants 2010 rates for mid-Hudson region. The proposed costwith study will determine whether these rates provide Other HCRA issues the Department seeksby tothe address include needpackage to clarify: (1)of whether itseveral isMedicare providers or payors that remit associated copayments and deductibles and (2) what ?appropriate Implement provider specific, aggregate annual per that patient spending limits ontransportation each agency based on provider-specific paid Medicaid claims per patient during The savings from the limits would statutory limits thatand drive cost. actual paid claims updated CaseonMix. Providers reduced their aggregate per PC patient spending levels below theSPA limitaverage would requires receive athe payment and providers that did 2009. not cost adjust their spending levels would compensation for services furnished under SSHSP and for special costs. Approved SSHSP #09-61 State to conduct a transportation study, assessing direct and information payors should provide their beneficiary cards The current by capital rate setting methodology for nursing homeswould is based upon two types of ownership structure - private, for-profit homes (i.e., proprietary homes) and not-for-profit, homes (i.e., public (including be captured reducing payments to PC providers. Payments be reconciled using actual paid claims. Providers that reduced their aggregate per patient spending levels below the limit would receive a have their payments further reduced. Please see Attachment #1 for an example of how the provider limits would be calculated. indirect costs within the parameters of OMB circular A-87, to establish new rates for special transportation, and to demonstrate to CMS that the new rates do not exceed actual costs. The medical services subject Implement aMedical Statewide pricing methodology for nursing homes thatnon-salary is adjustedcosts for differences in labor costsfor and case mix, provides a multi-year transition pool to facilitate a smooth transition to the new price, county and homes) and voluntary homes). 1. Direct covers the salaries, fringe benefits, andorallocated overhead residents, fellows, andfor supervising payment andState-operated providers thatby did not adjust their spending levels would have their rates payments further anphysicians. example howphysician the provider limits wouldnursing be calculated. to a promotes cost study will beEducation expanded to include allincentive services reimbursed to SSHSP providers, including therapy, psychology, and services. Depending onhome the cost study and quality care funding quality payments. This proposal will also transitionphysical/speech/occupational AIDS reduced. specialty Please rates tosee the"Attachment" new pricenursing, forfor nursing homes.ofBeginning in the Fall of 2013, patients results, consideration may also be given to enhancing the services delivered under this program. will begin to transition to Managed Long Term Care and Medicaid Managed Care (see proposal #90). Fee-for-service dental payments should be reduced matchdates ratesbetween paid by managed providers on high volume dental procedures. The following proposals would be implemented on to various 4/1/2011 care and 1/1/2012: It is ...
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