CHCANYS Conference

  • Presentation is also available in Portable Document Format (PDF)

October 21, 2014

Agenda

Rate Setting Process

Statewide Rate Processing

  • Statewide Rate Processing Steps:
    • Analyst develops rate package
      • Extraction of data
        • Is the data available?
      • Impact development
      • Rate sheet development
      • Division of the Budget letter
      • Dear Administrator letter
  • Statewide rate package is completed and submitted for internal department review
    • Supervisor
    • Chief Health Care Fiscal Analyst
    • Bureau Director
    • Assistant Division Director
    • Division Director
    • Medicaid Director
  • Rates provided to Managed Care Unit for wrap rate development
  • Appeal packet submitted to the Division of the Budget for review and approval
    • Similar chain as the Department of Health
  • When Division of the Budget approval received
    • Rates prepared for loading to eMedNY system
      • Transmittal document with electronic transmission of rate
      • All rate codes, All locations
    • Approval requested from Division office for loading of rate due to Global Cap affect
    • Rate transmitted and documentation forwarded
      • Overnight load process
      • Electronic file run thru edits
      • Edit review
      • Thursday cycle processing
  • Health Commerce System
    • Programming developed for posting
      • Dear Administrator letter
      • Rate Sheet

Appeal Rate Processing

  • Appeal Rate Processing Steps:
    • Providers submit an appeal request to BAMCR
      • Mr. Michael Ogborn
        Director
        Bureau of Acute and Managed Care Rate–Setting One Commerce Plaza – Room 1405
        99Washington Avenue
        Albany, New York 12210
      • Change to be implemented
    • Appeal request is reviewed for appropriateness by rate analyst
    • Appeal number assigned and acknowledgement letter sent to provider
    • Appeal is developed for Fee–for–Service rate:
      • Fee–for–Service Rate Calculations
      • Bureau Recommendation
    • Appeal Medicaid Managed Care Wrap Rate developed
      • Analyst calculate
      • Supervisor reviewed
    • Appeal packet is completed and submitted for internal department review
      • Fee–for–Service Supervisor
      • Chief Health Care Fiscal Analyst
      • Bureau Director
      • Assistant Division Director
      • Division Director
      • Medicaid Director
  • Appeal packet submitted to the Division of the Budget for review and approval
    • Similar chain as the Department of Health
  • When Division of the Budget approval received
    • Rate prepared for loading to eMedNY system
      • Transmittal document with electronic transmission of rate
    • Division office approval for loading of rate due to Global Cap affect
    • Rate transmitted and documentation forwarded
      • Overnight load process
      • Electronic file run thru edits
      • Edit review
      • Thursday cycle processing
  • Bureau recommendation mailed to Provider
    • Recommendation letter, appeal packet and attachments, if applicable
    • Hardcopy mailed – certified

Adding a Rate to eMedNY for a New Provider or New Location

  • Processing Steps:
    • Location rate establishment
      • New Provider
        • Provider submits enrollment application (refer to Contacts)
        • Provider Enrollment forwards a "Rate Setter Notification" to the BAMCR contacts with eMedNY details
        • Rate loaded when provider´s appeal has received Division of the Budget approval
    • New location based on Certificate of Need Application
      • Provider Enrollment forwards a "Rate Setter Notification" to the BAMCR contacts with eMedNY details
    • Provider Enrollment contact: providerenrollment@health.ny.gov
  • If a provider with FQHC locations
    • Provider contacted for HRSA approval
    • Copy of "Rate Setter Notification" provided to Medicaid managed care for wrap rate
  • Rate Loading
    • Rate prepared for loading to eMedNY system
      • Transmittal document with electronic transmission of rate
    • Approval requested from Division office for loading of rate due to Global Cap affect
    • Rate transmitted and documentation forwarded
      • Overnight load process
      • Electronic file run thru edits
      • Edit review
      • Thursday cycle processing

Processing Order

  • Processing Order:
    • Prioritize
      • Payment Issues
      • Appeals
        • Provider does not have a Medicaid rate
        • Provider is converting to an FQHC rate
        • Added Capital or Scope of Services
  • Appeals:

By Appeal Type

Appeal Type FQHC Non‐ FQHC Total
New Provider / Convert to FQHC 2 12 14
Added Capital / Capital Revisions 4 12 16
Scope of Services 2 N/A 2
Total 8 24 32

By Status

Status FQHC Non‐ FQHC Total
Waiting Processing / Initial Review 5 17 22
At the Division of the Budget 1 1 2
Final Processing 2 6 8
Total 8 24 32

Additional Processing Information

Health Commerce System (HCS)

  • Health Commerce System: https://commerce.health.state.ny.us/hcsportal/hcs_home.portal
    • Communication Tool
      • Secure network for posting provider information
        • FQHC & APG Capital Rate Sheets, AHCF Cost Report, Indigent Care
      • Keep email address current
        • Facility’s responsibility
        • Email blast separate from public website Electronic Mailing List
      • Removal of employee when they leave your employment
    • HCS Contacts
      • Commerce Accounts Management Unit (CAMU): 1–866–529–1890
        • HCS accounts
        • Password resets
        • removal of employee
        • New DTC to get established on the HCS
        • DTC does not have a Director or Coordinator
      • General HCS inquiries: 518–473–1809
        • Ask for Commerce Trainers
      • BAMCR at dtcffsunit@health.ny.gov
        • Receiving access to the D&TC applications 12

Contacts

  • Bureau of Acute & Managed Care Rate Setting (BAMCR)
  • Contacts outside of BAMCR:
    • Contact Computer Sciences Corporation (CSC) at 800–343–9000
      • Has my Provider Enrollment application been received?
      • What is the status of my Provider Enrollment application?
      • How do I submit a claim or why did my claim deny?
    • Medicaid Financial Management at mfm@health.ny.gov
      • Liability balance
      • Payment on a liability
    • Contact Provider Enrollment at providerenrollment@health.ny.gov
      • Is my location established on eMedNY?
    • Bureau of Vital Access Provider Reimbursement at bvapr@health.ny.gov
      • Questions regarding AHCF Cost Report
    • Bureau of Federal Relations and Provider Assessments at william.hogan@health.ny.gov
      • Questions regarding Indigent Care

Total Medicaid Spending Over Time

State Fiscal Years 2003–13

NYS Statewide Total Medicaid Spending (CY2003–2013)

NYS Statewide Total Medicaid Spending
  2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
# of Recipients 4,267,573 4,594,667 4,733,617 4,730,167 4,622,782 4,657,242 4,911,408 5,212,444 5,398,722 5,598,237 5,792,568
Cost per Recipient $8,469 $8,472 $8,620 $8,607 $9,113 $9,499 $9,574 $9,443 $9,257 $8,884 $8,504

*Projected Spending Absent MRT Initiatives was derived by using the average annual growth rate between 2003 and 2010 of 4.28%.
Excluded from the 2013 total Medicaid spending estimate is approximately $5 billion in "off–line spending" (DSH, etc.)

NYS Statewide Total Medicaid Spending per Recipient (CY 2003–2013)

NYS Statewide Total Medicaid Spending per Recipient
  2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
# of Recipients 4,267,573 4,594,667 4,733,617 4,730,167 4,622,782 4,657,242 4,911,408 5,212,444 5,398,722 5,598,237 5,792,568
Cost per Recipient $8,469 $8,472 $8,620 $8,607 $9,113 $9,499 $9,574 $9,443 $9,257 $8,884 $8,504

NYS Statewide Total Medicaid Spending for All Categories of Service Under the Global Spending Cap (CY 2003–2013)

NYS Statewide Total Medicaid Spending for All Categories of Service Under the Global Spending Cap
  2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
# of Recipients 4,266,538 4,593,566 4,732,564 4,729,167 4,621,911 4,656,361 4,910,528 5,211,559 5,397,870 5,597,551 5,791,893
Cost per Recipient $7,635 $7,657 $7,787 $7,710 $8,158 $8,467 $8,520 $8,386 $8,277 $8,008 $7,929

*Projected Spending Absent MRT Initiatives was derived by using the average annual growth rate between 2003 and 2010 of 4.28%.

NYS Statewide Total Medicaid Spending per Recipient for All Categories of Service Under the Global Spending Cap (CY 2003–2013)

  2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
# of Recipients 4,266,538 4,593,566 4,732,564 4,729,167 4,621,911 4,656,361 4,910,528 5,211,559 5,397,870 5,597,551 5,791,893
Cost per Recipient $7,635 $7,657 $7,787 $7,710 $8,158 $8,467 $8,520 $8,386 $8,277 $8,008 $7,929

*Projected Spending Absent MRT Initiatives was derived by using the average annual growth rate between 2003 and 2010 of 4.28%.

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Where We Are

Current State of Medicaid

Current Status of Medicaid Global Cap

Medicaid Spending – FY 2015 (dollars in millions)
Category of Service Estimated Actual Variance
Over /
(Under)		  
Medicaid Managed Care $1,016 $999 ($17)
  • Total State Medicaid
    expenditures under the
    Medicaid Global Spending
    Cap for FY 2015 through April
    are $7 million or 0.5 percent
    under projections. Spending
    for FY 2015 resulted in total
    expenditures of $1.38 billion
    compared to the projection
    of $1.39 billion.
         Mainstream Managed Care $750 $732 ($18)
         Long Term Managed Care $266 $267 $1
Family Health Plus $59 $62 $3
Total Fee For Service $686 $677 ($9)
         Inpatient $278 $276 ($2)
         Outpatient/Emergency Room $36 $43 $7
         Clinic $56 $60 $4
         Nursing Homes $320 $307 ($13)
         Other Long Term Care $73 $71 ($2)
         Non‐Institutional ($77) ($80) ($3)
Medicaid Administration Costs $38 $33 ($5)
OHIP Budget / State Operations $18 $7 ($11)
Medicaid Audits ($35) ($32) $4
All Other $315 $344 $29
Local Funding Offset ($709) ($709) $0
TOTAL $1,388 $1,381 ($7)

Global Cap Risk Factors

  • ACA enrollment – We are now serving more people than ever before: 6,269,841 (for Calendar Year 2013).
  • $300 million contribution to the financial plan (tax cut) and $445 million transfer to the Mental Hygiene Stabilization Fund.
  • Full implementation of Wage Parity in NYC for SFY14–15 is $420 million. The distribution is as follows:
    • MLTC Risk Rates – $225M; MLTC Mandatory Rates – $75M; Fee–For–Service – $50M; Quality Incentive Vital Access Provider Pool (QIVAPP) – $70M
  • Complex year with lots of "puts and takes." Need to monitor very closely.

VAP/Safety Net Program

  • 2014–15 Enacted Budget includes $194 million in VAP funding of which $30 million continues to be set aside for Financially Disadvantage Nursing Homes.
  • Over 180 applications, with a total estimated request of $1.2 billion (excluding capital), have been received to date.
    (dollars in millions) 2013‐14 2014‐15
    Total Funding Available $182 $194
    VAP Awards (committed in 2013‐14) $156 $62
    VAP Awards (to be committed in 2014‐15) N/A $83
    Remaining Funding Available $26 $49
    Move 13/14 into 14/15 ($26) $26
    Available Funds $0 $75
  • Available Funds are to be used to support providers as they transition to DSRIP or those providers that do not qualify for DSRIP.
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Big Reforms Ahead:
Agenda for the Next Six Months

  • Nursing Home benefit being carved into managed care: January 2015
  • FIDA – Fully Integrated Duals Advantage Program:
    • NYC/Nassau County: Voluntary enrollment begins on January 1, 2015 with passive in April 2015.
    • Westchester/Suffolk Counties: Voluntary enrollment begins April 1,2015 with passive in July 2015.
  • HARP/Behavioral Health Carve–In
    • April 1, 2015 – BH Adults transition in NYC
    • October 1, 2015 – BH Adults transition Rest of State
    • April 1, 2016 – BH Children transition Statewide
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MRT Waiver Amendment

On April 14, 2014 Governor Andrew M. Cuomo announced that New York finalized agreement with the Federal government for a groundbreaking waiver that will allow the State to reinvest $8 billion in Federal savings generated by Medicaid Redesign Team (MRT) reforms.

  • Allows the state to reinvest $8 billion of the $17.1 billion in federal savings generated by MRT reforms.
  • Funds will address critical issues throughout the State and allow for comprehensive reform through a Delivery System Reform Incentive Payment (DSRIP) program. The program will:
    • Focus on system reform, specifically a goal to achieve a 25 percent reduction in avoidable hospital use over five years.
    • Payments are based on performance and outcome milestones.
    • Require providers to collaborate to implement innovative projects focusing on system transformation, clinical improvement and population health improvement.

MRT Waiver Allocation Plan

The $8 billion reinvestment will be allocated in the following ways:

  • $500 Million for the Interim Access Assurance Fund (IAAF) – Time limited funding to ensure current trusted and viable Medicaid safety net providers can fully participate in the DSRIP transformation without unproductive disruption.
  • $6.42 Billion for Delivery System Reform Incentive Payments (DSRIP) – Including DSRIP Planning Grants, DSRIP Provider Incentive Payments, and DSRIP Administrative costs and DSRIP related Workforce Transformation.
  • $1.08 Billion for other Medicaid Redesign Purposes – This funding will support Health Home development, and investments in long term care workforce and enhanced behavioral health services, (1915i services).

Value Based Payments

Per Special Terms & Conditions §39, all contracted MCOs must employ non–fee–for–service payment systems that reward value over volume for at least 90% of all their provider payments by Waiver Year 5

  • The goals of Value Based Payment Reform is to:
    • Create integrated delivery systems that are more accountable for quality of care provided and make providers assume greater financial risk;
    • Increase the linkage between quality and cost; and
    • Ensure service delivery focuses on high–quality care at a lower cost in a coordinated full continuum of care within emerging Performing Provider Systems (PPS)
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Questions?

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