Managed Care Update

Carl J. Pucci in Finance & Reimbursement


DOH presented its’ Medicaid Managed Care webinar yesterday (following the DOH meeting held last week with downstate providers and associations.)

The webinar followed previous Managed Care briefings focusing on the OHIP policy document, which remains the blueprint for the transition from a Fee For Service (FFS) to Managed Care environment.

DOH, at the outset of the webinar, stated it still does not have CMS approval, and if not received by the 4/1/14 implementation date (NYC/LI/Westchester), the transition timelines will again be delayed.  The DOH PowerPoint expands upon the policy statement referenced above, and references continuous feedback following the sub-workgroups (Network & Contracting, Eligibility & Enrollment, Access and Quality, and Finance & Reimbursement) input.

Since much of the information presented has previously been issued and discussed, this mailing highlights key areas, and/or new information related to each area (again, members are urged to carefully review both the policy document and PowerPoint for further details related to the transition.)


  • Phase-in schedule (slide 4), as previously announced (still subject to CMS approval).
  • Pharmacy services (slide 7) – absent negotiated agreement, current pharmacy arrangements must be honored during 3 year transition period.
  • Bedhold policy remains intact, unless alternatively negotiated (slide 8).

Network & Contracting

  • Standard nursing home network requirements (slide 10)
  • Provider contracting (slide 12)
  • Provider due process and appeal rights must be included.
  • Contracts must be negotiated in good faith.

Eligibility and Enrollment

  • LTC placement consistent with current practice and regulation
    • MCO must authorize
    • Nursing Home transmits LDSS-3559
  • Restriction/exemption codes (slide 19 – 20), which will identify type of LTC placement, as well as drive MC premium rate payment.
  • Rosters (slide 21) – SNFs will continue to receive their FFS rosters via current delivery method (will include rate and exception codes)
  • NAMI – DOH’s position is that the MCO/provider contract should specify collection of the NAMI.
  • Enrollment scenarios – (slides 25 – 27)
    • Three scenarios provided for current enrollees (Prior and Post 4/1/14), as well as New enrollees (post 4/1/14).
      • Note:  no change to Current enrollee scenario (Prior 4/1/14)

Note:  DOH acknowledged the complexity of the eligibility and enrollment process, as well as many unanswered provider questions.  They plan on scheduling another conference call to deal with these issues.|

Access to Care/Transitions

  • Hospital, Nursing Home and MCOs role each defined (slides 31 – 36).
  • Transition challenges (slides 37 – 38).
    • Two DOH Hotlines established for care plan/placement disagreements.
  • All current appeal rights remain intact.
  • Eligibility and placement timeline (slide 43)
    • Note that plan payments will occur at the time of admission (should significantly reduce current “Medicaid Pending” cash flow issues.)

Finance and Reimbursement

  • Various finance issues and discussion points are outlined (slides 45 – 50), many of which reiterate or expand upon the policy document, namely:
    • FFS rates in place for three years
    • FFS rates to be updated biannually for CMI adjustments
    • Ancillary service billing defined (slide 47)
    • Retroactive rate changes must be paid to providers by MLTCP’s
    • Capital pass-thru provision
    • Benchmark rates defined
      • Note:  DOH weblink with facility-specific benchmark rates established (can be appended to provider/MLTCP contracts)
    • NAMI/Personal Needs Funds Allowance Guidance (slide 51)

DOH discussed association and providers concerns related to cash flow.  They noted that most MLTCP’s can accept bi-weekly electronic billings.  They also would consider temporarily reducing the two-week Medicaid payment lag for providers who experience significant cash flow issues related to the transition.  NYSHFA continues to strongly advocate for prompt payment safeguards.


There still remain open issues with CMS, most notably capital (post transition period), risk mitigation pools, and blending of rate cells.

We are presently awaiting clarification on whether DOH was able to record yesterday’s webinar, as technical difficulties still existed.  Should the webinar recording become available, we will alert members.  Members should continuously review the Managed Care sections of both the DOH and NYSHFA websites for continuous updates related to the Managed Care transition.

Director, Finance & Reimbursement
518-462-4800 x36