CHCANYS Conference

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

October 20, 2016

Mr. Michael Ogborn
Deputy Director
Division of Finance and Rate Setting

Ms. Janet Baggetta
Chief Health Care Fiscal Analyst
Bureau of Acute and Managed Care Rate Setting


Uncompensated Care

  • Request for Amendments to CMS 1115 Waiver sent August 2015
  • Seeks an extension through March 31, 2017 while maintaining current methodology
  • Eligible facilities are required to:
    • Provide a comprehensive range of primary/mental health care services;
    • Deliver at least five percent of their visits to uninsured individuals; and
    • Have a process for collecting payments from third party payors.
  • DOH is moving forward with State only payments (9 months)
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Vital Access Provider (VAP)

  • Release of VAP funding to DOH approved providers
    • Contingent upon obtaining approval from the federal Centers for Medicare and Medicaid Services (CMS) for the applicable NYS Medicaid State Plan Amendment (SPA) and subsequently federal financial participation (FFP).
    • The FFP is 50% for FQHCs
    • The Department is aware of the impact of the payment delay on VAP awardees
    • State share payments have been released to all FQHCs
    • The Department has been, and continues to be, in constant communication with CMS
  • DOH and CMS have agreed to pay the FQHC VAP awards using the following methodology
    • The supplemental payment will be distributed between fee–for–service (FFS) and the wrap payment based on the percentage relationship between the FQHC rate and the wrap rate.
    • The FFS portion will be included in the VAP SPA and subject to the threshold test of 10% of annual FFS Medicaid payments.
      • This is referred to as the Economy and Efficiency Test
  • Contact the Bureau of Vital Access Provider Reimbursement
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October 1, 2015 FQHC Rate Update

  • Rates completed and in the Department´s review stage
    • Proposed Operating Cost Increase
      • Medicare Economic Index (MEI) for 10/1/2015 is 0.8%
      • Rate update includes: FFS, MMC Wrap & Litigation Rates
      • Ceilings posted on the Department´s public website when approved by the Division of the Budget
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FQHC Hold Harmless Calculation

  • September 1, 2009 through December 31, 2013 completed
    • Dear Administrator letter and schedules posted to the Health Commerce System (HCS) on August 11, 2015
    • Retro rate reprocessing occurred in cycle 1981
    • Why paid as an APG rate add–on versus lump sum?
    • Outstanding issue
  • January 1, 2014 through December 31, 2014
    • Calculation in review within the Department
      • Target lump sum payment by end of year
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Trending of Group Psychotherapy and Offsite Rates

  • State Plan Page 2(c)(iv)
    • Federally Qualified Health Centers & Rural Health Clinics
      • Specifically provides for increasing the PPS rate by the MEI
      • Did not provide for any change to the group psychotherapy and offsite rates
      • Inquired with CMS
  • State Plan Amendment (SPA) 15–0039
    • Federal Public Notice (FPN) in NYS Register April 29, 2015
      • Increased both rates effective May 1, 2015 by the MEI
  • SPA approved May 20, 2016
  • Request for Additional Information (RAI) received from CMS
    • Trend rates from 2006 base year
    • MEI Roll factor from 10/1/2007 through 10/1/2014
    • May 1, 2015 Rates:
        Group Psychotherapy Offsite
      Upstate $34.59 $61.21
      Downstate $38.56 $68.52
    • When SPA approved, update for the 10/1/2015 MEI
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FQHC Rate Appeals

  • Appeal Rate Processing and Approval
    • Providers submit an appeal request to:
      • Mr. Michael Ogborn
        Deputy Director
        Division of Finance and Rate Setting
        One Commerce Plaza – Room 1432
        99 Washington Avenue
        Albany, New York 12210
    • 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
    • Appeal Medicaid Managed Care Wrap Rate developed
    • Appeal submitted for Department review and approval
    • Appeal submitted for Division of the Budget approval
  • Appeal Rate Payment Steps:
    • When Division of the Budget approval received
      • Rate prepared for loading to eMedNY system
        • Transmittal document with electronic transmission of rate
        • In order to transmit rate, the provider needs to be enrolled in New York Medicaid, have a Medicaid Provider Number and Location Code established
      • 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
  • Part 86–4.16 Revisions in certified rates

    "(a) The commissioner shall consider only those applications for prospective revisions of certified or approved rates which are in writing and which address one or more of the issues set forth in this section."

    "(c) Documented increases in the overall operating costs of a facility resulting from the implementation of additional or expanded programs, staff or services specifically mandated for the facility by the commissioner may be the basis for an application for prospective revision of a certified or approved rate..."

    "(d) Documented increases in overall operating costs of a facility resulting from capital renovation, expansion, replacement or the inclusion of new programs, staff or services approved by the commissioner through the certificate of need (CON) process may be the basis for an application for revision of a certified rate..."

    "(e) Upon receipt of actual cost data for appeals pursuant to subdivisions (c) and (d) of this section, the modified rate based on projections will be retroactively revised to reflect actually incurred costs held to operating cost ceiling limitations and utilization standards set forth in this Subpart."
  • Budget to Actual Cost Process
    • Implementing actual costs not new
    • "C" appeal tracking process is new
  • Appeal write up will provide
    • "C" appeal number assigned
    • Cost base year that will be used and effective date of the rate update
  • Processing Order
    • Prioritize
      • Appeals:
        • Provider does not have a Medicaid Rate
        • Provider is converting to FQHC
      • Payment Issues
      • Statewide Rate Packages
      • Appeals:
        • Added Capital or Scope of Services
  • Status of Appeals

    Appeal Type Count of Appeals Status of Appeal
    Waiting Processing / Initial Review In Department Review At the Division of the Budget Final Processing Stage
    New Facility (FQHC) 1 0 0 0 1
    New Facility (APG) 12 7 3 1 1
    Capital Rate Update 3 2 0 0 1
    Scope of Services 2 2 0 0 0
    Budget to Actual Facility Request 1 0 0 1 0
    Budget to Actual C Appeals 5 5 0 0 0
    Total Appeals 24 16 3 2 3
    • To date in 2015, 46 appeals have been completed for freestanding providers and hospital FQHCs
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Electronic Health Records

  • Authorization
    • Section 364–j–2 of the Social Services Law, and
    • State Plan Amendments (SPAs) #08–40 and #09–31
  • Supplemental payment of $7,388,000
    • For each of the periods 10/1/08–12/31/08 and 10/1/09–12/31/09
    • Made to eligible covered providers as medical assistance payments for services provided to Medicaid beneficiaries to reflect additional costs associated with the development, training, maintenance, and support of electronic health record systems (EHRS).
  • Data Requirements
    • Must have submitted a EHRS Survey with proper documentation by designated deadline.
    • Must submit base year AHCF–1 cost report with all required documents (CEO & CPA certification and Audited F/S).,
    • Medicaid visits must be at least 25% of total threshold visits, or Medicaid visits and Uninsured visits* must be at least 30% of total threshold visits.
      • *Uninsured Visits = Self–Pay Visits + Free Visits
  • Payment Issues
    • Lump sum payment versus Add-on to FQHC rate
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2014 AHCF Cost Report

  • Summary screens for 2014 for APG Capital Calculation
    • Article 28 APG capital rate calculation noticed to providers on October 14, 2015
    • Displays the summation of a facility´s ARTICLE 28 SERVICES ONLY
    • Summary screens require no action by providers
    • Why?
    • Screens included in the update:
      • Exhibit I, Part C
      • Exhibit I, Part D
      • Exhibit III, Part A
      • Exhibit III, Part F
    • Exhibit III, Part A provides the APG base year capital rate for providers to review and submit with the cost report.
  • For the facility to develop the capital rate accurately, the following is required:
    • Providers must appropriately select the proper category/categories for their cost and statistical reporting on the configuration screen AND
    • Providers must discretely report the dually certified mental hygiene services
  • In order to properly categorize the APG capital rates, the following changes were made to the configuration screen:
    • "07 = Dental" has been revised to "07 = Academic Dental"
      • Non–academic dental providers should use category "16 = Dental (Non–Academic)" for reporting purposes
    • "16 = Statewide No Group" has been revised to "16 = Dental (Non–Academic)"
      • The "Statewide No Group" category has been removed from the cost report selection
        • If a provider previously used this category, the proper category to select is "12 = Other / One–of–a–Kind."
  • Facility Update Sheet
    • Required question for all providers to be answered in order for dental costs and visits to be included in the proper category for the APG rate development:
      • "Are you an Academic Dental School Provider?"
        The cost report will not be able to be submitted without responding to this question.
  • Exhibit I, Part D (Statistical Data by Payer)
    • Visits OR procedures should be reported based on the appropriate statistic for the service
    • The AHCF cost report instructions provides details as to which statistic should be reported
      • Page 6 of instructions
  • Why keep all the categories?
    • Analysis purposes
    • Distribution calculations such as the Indigent Care Pool
  • When released?
    • Currently with programmers
    • 2015 AHCF Cost Report
  • Cost Report Contact
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Health Commerce System (HCS)

  • 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) Help Desk:
      1–866–529–1890 or
      • HCS accounts
      • Password resets
      • removal of employee
      • New DTC to get established on the HCS
      • DTC does not have a Director or Coordinator
    • Email
      • Receiving access to the D&TC applications
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Department of Health Public Website

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  • Bureau of Acute & Managed Care Rate Setting (BAMCR)
  • Contacts outside of BAMCR
    • Contact Computer Sciences Corporation (CSC) at 1–800–343–9000
      • 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
      • Liability balance
      • Make a payment on a liability
    • Contact Provider Enrollment at
      • Is my location established on eMedNY?
    • Bureau of Vital Access Provider Reimbursement at
      • Questions regarding AHCF Cost Report
    • Bureau of Federal Relations and Provider Assessments at
      • Questions regarding Indigent Care
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