New York State Medicaid Updates. John W. Gahan Jr., Bureau of Vital Access Provider Reimbursement

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1 New York State Medicaid Updates John W. Gahan Jr., Bureau of Vital Access Provider Reimbursement 1

2 Agenda Division of Finance and Rate Setting Reorganization Global Cap - Update Inpatient Rates and Adjustments Safety Net/VAP ICR Reporting Questions and Answers 2

3 Division of Finance and Ratesetting (DFRS) Bureau Director Responsibilities Acute and Managed Care Ratesetting Mike Ogborn Managed care Rates FFS Rates (Inpatient) FFS Rates (Outpatient and Clinics) Stop Loss Program Wrap/Hold Harmless Long Term Care Ratesetting Steve Simmons MLTC Rates FFS Rates NH Operating/prices FFS Rates Other LTC FFS Rates Foster Care, ALP, Hospice Vital Access Provider Reimbursement John Gahan Provider Financial assistance VAP/SN Program Cost reports Capital reimbursement NH Litigation Disaster Response/Special Analysis 3

4 DFRS Reorganization Bureau Director Responsibilities Federal Relations and Provider Assessments Roland Guilz Financial Analysis/Special Projects UPL calculations Indigent Care/DSH Federal Relations MRT Waiver, State Plans, Provider Assessment Admin Systems support Global Cap/Administration Vacant Global Cap OHIP Budget OHIP Admin Mental Hygiene Services Ratesetting Donna Cater All Mental Health Rate Setting OMH, OASAS, OPWDD 4

5 Global Cap Update Enacted Budget increased global cap from $15.9B to $16.4B ($510M or 3.2%) Components of $510m: Price (+$490 million) Price includes managed care premium adjustments for cost trends and newly covered benefits, as well as fee-for-service rate adjustments. See Appendix A for more detail. Utilization (+$140 million) Utilization reflects the annualization of FY 2013 net enrollment growth (108,300 recipients) as well as assumed new enrollment for FY 2014 (127,000 recipients). MRT/One-Timers/Other (-$120 million) MRT/Other primarily includes an increase of $190 million in local county contributions reflecting the return of Monroe County to the program offset by lower than expected rebates due to the shift of drugs from brand to generic. 5

6 Global Cap Update FY 2014 Global Cap Breakout (dollars in billions) All Other $1.7 Fee For Service $9.7 Managed Care $12.4 NOTE: This chart represents the projected non-federal share of Medicaid spending for this fiscal year. $23.8 billion of Medicaid State services are funded by $16.4 billion in the Medicaid Global Spending Cap and $7.4 billion from local contributions. 6

7 Millions Global Cap Update Accounts Receivable balance at the end of September was $234M which reflects a reduction of $166M since April. OHIP Budget moved under Global Cap FY 2014 OHIP Budget (dollars in millions) $200 Budget Spending To Date $162 $150 $100 $50 $29 $5 $3 $0 Personal Services Non-Personal Services 7

8 Global Cap Update Medicaid Spending FY September (dollars in millions) Category of Service Estimated Actual Variance Over / (Under) Total Fee For Service Inpatient Outpatient/Emergency Room Clinic Nursing Homes Other Long Term Care Non-Institutional Medicaid Managed Care Family Health Plus Medicaid Administration Costs Medicaid Audits OHIP Budget / State Operations All Other Local Funding Offset TOTAL $5,184 $5,132 ($52) $1,440 $1,426 ($14) $256 $232 ($24) $329 $364 $35 $1,695 $1,691 ($4) $633 $607 ($26) $831 $812 ($19) $5,417 $5,431 $14 $472 $465 ($7) $259 $239 ($20) ($326) ($334) ($8) $51 $52 $1 $923 $948 $25 ($3,746) ($3,746) $0 $8,234 $8,187 ($47) 8

9 Global Cap Update Medicaid total enrollment reached 5,386,281 enrollees at the end of September: NYS Medicaid Enrollment Summary FY 2014 March 2013 September 2013 Increase / (Decrease) % Change Managed Care 3,936,431 4,054, , % New York City 2,574,775 2,616,527 41, % Rest of State 1,361,656 1,438,447 76, % Fee-For-Service 1,314,647 1,331,307 16, % New York City 626, ,535 26, % Rest of State 687, ,772 (9,895) -1.4% TOTAL 5,251,078 5,386, , % New York City 3,201,755 3,270,062 68, % Rest of State 2,049,323 2,116,219 66, % 9

10 Inpatient Rates and Adjustments 2009 Medicaid Managed Care Rates Premiums originally adjusted starting 1/25/2013 Rate schedules sent to all Health Plans this week Guidance provided to all Health Plans as to the rates being published Re-processing between hospitals and plans per their established contracts Plans and hospitals expected to process as expeditiously as possible These are considered final 2009 Managed Care Rates Posted to HCS 10

11 Inpatient Rates and Adjustments 2013 Rates Acute 2013 Budgeted Capital (2010 Traceback %) New CMIs using V30 of APR-DRG based on 2010 cases WC/NF Statewide Price will be trended 1.4% 2013 Initial Trend 1/1/13 3/31/13 Updated statewide price for 2013 average APR-DRG Transition I: Final payment for the 4/1/12 3/31/13 $25M allocation Transition II: Final payment for the 4/1/12 3/31/13 $50M allocation 11

12 Inpatient Rates and Adjustments 2013 Rates - Acute 4/1/13 12/31/13 Transition I: Pool value set to $0. No affect on Statewide Price. Transition II: Pool value set to $25M. $25M reduction added to Statewide Price. PPRs/PPCs, known as PPNOs Received CMS approval Effective 7/1/2012 Adjustment implemented 1/1/13 $47M for PPR s and $4M for PPC s 12

13 Inpatient Rates and Adjustments 2013 Rates Exempt Units excluding Psychiatric All rates effective 1/1/13-12/31/13 Trended for WC/NF (1.4%) 2013 budgeted capital (2010 TB %) Psychiatric Units Transition pool drops from $17M to $8.5M with the $8.5 going into the statewide price Trended for WC/NF (1.4%) 2013 Budgeted capital (2010 Traceback%) 13

14 Inpatient Rates and Adjustments 2014 Rates: Delayed till 4/1/ rates to be paid till then Acute Rates: Moved from 2005 to 2010 audited cost Updated WEF to 2010 CMS data 2014 Budgeted Capital GME based upon 2010 IME survey data and staffed beds per 2010 ICR GME divisor is 2011 Medicaid FFS paid claims and Managed care encounter data Trend is only applicable to WC/NF rates Exempt Unit rates Based upon 2013 rates but 2014 budgeted capital 14

15 VITAL ACCESS PROGRAM (VAP) 15

16 Available Funding The Enacted Budget allocated $152 million for VAP/Safety Net Programs and $30 million for Financially Disadvantaged Nursing Homes Financially Disadvantaged Nursing Homes VAP/Safety Net Total Total Available Funding $30 M $152 M $182 M Phase 1 Funding (Years 1 and 2) $15.9 M $39.7 $55.6 M Phase 2 Award Funding $4.1 M $41.4 M $45.5 M Remaining Funds $10.0 M $70.9 M $80.9M The appropriation is $154M 16

17 Status of VAP I Awards 13 Plans approved for a total of $69 million for 3 years CMS Status Nursing Home funding approved D&TCs pending approval Hospital funding split into two categories: Without customary charge cap limitations pending approval With customary charge cap limitations Working with providers to revise data resolution continues to be pursued with CMS If VAP program outpatient we moved to outpatient UPL 17

18 Status of VAP I Awards Next Steps: Initial Payments to be made in Cycle 1895 Expect quarterly reports to be submitted by January 15 th, 2014 Second payment to be made before March 31,

19 VAP II Applications 156 applications, with a total estimated request of $1.1 billion (excluding capital), received to date Phase 2 Plans by Provider Type Provider Type Number of Providers Number of Plans Total Project Cost (Excluding Capital) Hospital (CAHs) $ 21,222,884 Hospital (Non-CAHs) $ 618,081,092 Nursing Homes $ 114,308,950 D&TCs $ 285,284,796 CHHAs 6 6 $ 24,119,573 Total $ 1,063,017,295 19

20 VAP II Applications Applications were divided into 3 categories utilizing a three year average operating margin: 76 Negative Operating Margins (Financially Distressed Facilities) and 20 CAHs (Critical Access Hospitals) or 96 plans 43 Non-CAHs with Positive Operating Margins below National Average 17 Positive Operating Margins above National Average 20

21 VAP II Applications VAP plans in the first category are being reviewed and scored Scores are based on qualifying criteria outlined in the MRT Reinvestment Program as follows: Facility Financial Viability Community Service Needs Quality Care Improvements Health Equity Executive summary/program description CAHs and Providers with Negative Operating Margins Provider Type Number of Providers Number of Plans Total Project Cost (Excluding Capital) Hospital (CAHs) $21,222,884 Hospital (Non-CAHs) $264,447,537 Nursing Homes $102,224,073 D&TCs $239,333,857 CHHAs 4 4 $8,059,791 Total $635,288,142 21

22 VAP II Applications VAP II Applications $41M awarded to 36 providers plus $5M set aside for CAH CAH check off application currently being completed to allocate the $5M Next Steps Facilities completing the full TMRRA applications Due January 8, 2014 Will review during January to be sure all components included including: Entire multi year budgets Objectives including steps and metrics 22

23 Reporting Facilities submit proposed metrics in full application After review and possible adjustment, DOH and facility reach agreement on metrics Each awardee will have unique metrics due to different objectives Divided into three categories to measure a plan s success Financial, operating, and quality Often interdependent or overlapping 23

24 Reporting Providers will be required to submit quarterly reports Reports will contain: Sources and uses of funds Narrative on progress towards goals Metrics and benchmarks status Data will be reported through a web based tool Reports will be posted to MRT web page Provides transparency and accountability Shows progress towards benchmarks 24

25 Strategic Planners Strategic Planners DOH would require some providers to involve a strategic planner to help develop, implement and monitor plans Strategic planner would Report to DOH and provide support to the provider Review and analyze quarterly reports for progress towards goals 13 VAP II Awardees assigned strategic planners 25

26 Cost Reports Audit Fees: ( ) Many facilities with outstanding fees Letter posted to HCS 2012 reviews Still several facilities that have not submitted or have not provided all components Staff completed very limited review Data sent to KPMG for the start of the audit process 26

27 Cost Reports 2013 what to expect: Additional critical edits as well some possible comparative data between report years Possible changes to Ex 46 due to Customary Charge requirement 27

28 QUESTIONS 28

HCA Presentation Ann Foster Division of Finance and Rate Setting Department of Health

HCA Presentation Ann Foster Division of Finance and Rate Setting Department of Health September 9, 2016 September 9, 2016 2 Agenda 2015 16 Global Cap Results Overview of 2016 17 Global Cap Projections