February 12, 2016 Edition of ASAP

ASAP

A Weekly Publication Of HCA Home Care Association of New York State

Legislative Issues  Public Policy

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News

Volume 21, No. 6 February 12, 2016

HCA Hones Budget Proposals, Minimum Wage Estimates, as Advocacy Presses Forward HCA op-ed outlines stakes of $15 minimum wage relative to key home care program, reimbursement needs “long left unaddressed” HCA took to the pages of the Times Union this week with an op-ed outlining one of our major positions and concerns – that the proposed $15 wage mandate must be funded and not draw energy or focus at a time when other home care program and reimbursement needs must be addressed in the state budget. We also held several meetings with high-ranking legislative staff, including an important partnership effort with the community health coalition, while continuing to plan alternative budget language as a point of negotiation for our budget asks. See HONES p. 3

State Posts Proposed Rule on Physician Order Change for Home Care As reported in an alert to the membership this week, the state has published a proposed rule, long sought by HCA, to provide flexibility in the physician order deadline for home care services, extending it from 30 days to a full year, consistent with federal standards and Medicare. The posting begins a 45-day comment period. HCA will be voicing our strong support, and we urge members to do the same. We also extend our appreciation to the state Department of Health for moving forward on this long-sought change. See ORDERS p.2 Inside ASAP HCA Hones Budget Proposals, Wage Estimates, Advocacy.............1 State Posts Rule on Physician Order Change for Home Care.............1 Member Hiring Announcements..........................................................3 Rule Requires Medicare Reporting, Returning of Overpayments......5 Flu Declared Prevalent; Mask Requirement in Effect..........................6 FLSA Funding Update..........................................................................7 Wage Parity Forms Due March 1...........................................................8 President Obama Releases 2017 Proposed Budget...........................9 DOH Publishes Proposed Hospice Rule..............................................9 Downstate LHCSA Forum: March 29.................................................10 Senior Financial Managers Summit is a Must-Attend Program........11 HHCAHPS Data Submission Tool Reopened....................................11 New Condition Code Issued for Claims w/o Skilled Visits..............12 DOH Requests LTHHCP Waiver Extension........................................13 Guidance Coming on TALs, other Emergency Prep Updates............13 Legal Update Stresses HIPAA Implications for Home Care..............14 CMS Proposes Prior Authorization Demo in Five States..................14 MLTC Advisory Group Explores Value Based Payment Models.......15 FIDA and MLTC Update.....................................................................16 HCA Provides Memo on NGS Home Care, Hospice Updates.........17 GoldSTAMP Committee Plans 2016 Initiatives..................................17 Progress on HCA’s Sepsis Screening Tool and Protocol...................18 Updated FAQs Released for Accountable Health Communities......19 Publications............................................................................................................19

HCA’s offices are closed on Monday, February 15, for President’s Day and will reopen on February 16.

Helping New Yorkers Feel Right At Home

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ORDERS from p. 1 Shortly after the notice was posted, HCA sent a statement to Crain’s Health Pulse to inform health business leaders about the proposal. “We appreciate the state’s support for a sensible timeline that has worked under Medicare,” said HCA President Joanne Cunningham, in a statement picked up by Crain’s. “This proposal ensures that providers and physicians can focus on the initiation or modification of the care itself.” The Crain’s article is posted to our “HCA in the News” page at http://hca-nys.org/category/ hca-in-the-news. DOH’s proposed rule would help home care agencies whose billing to Medicaid is hamstrung by late written physician orders and/or changes in physician orders. At present, home care providers have 30 days to receive the orders and a separate 90-day billing deadline, from the last date of service. A late physician order means that many providers have a narrow window to submit claims for reimbursement, as there is no exception code for late orders. The proposed rule, along with a planned change to the state’s Medicaid billing guidelines, would allow up to one year for obtaining the physician order and consequently, via exception code, for billing Medicaid to get paid. The state will address the billing deadline through a separate guidance. HCA will inform the membership when changes to the billing deadline are advanced. You can read the full rule at http://w3.health.state.ny.us/dbspace/propregs.nsf/ 4ac9558781006774852569bd00512fda/ee2bc32b1110865c85257f55006a5a.

ASAP is a weekly publication of the Home Care Association of New York State (HCA). Unless otherwise noted, all articles appearing in ASAP are the property of the Home Care Association of New York State. Reuse of any content within this newsletter requires permission from HCA. President: Editor:

Joanne Cunningham, jcunningham@hcanys.org Roger L. Noyes, Director of Communications, rnoyes@hcanys.org Al Cardillo, Executive Vice President, Policy & Programs, acardillo@hcanys.org Patrick Conole, Vice President, Finance & Management, pconole@hcanys.org Andrew Koski, Vice President, Program Policy and Services, akoski@hcanys.org Alexandra Blais, Director of Public Policy, ablais@hcanys.org Laura Constable, Senior Director, Membership & Operations, lconstable@hcanys.org Celisia Street, Director of Education, cstreet@hcanys.org Mercedes Teague, Finance Manager, mteague@hcanys.org Jenny Kerbein, Director of Governance and Special Projects, jkerbein@hcanys.org Billi Hoen, Manager, Meeting and Events, bhoen@hcanys.org Teresa Brown, Administrative Assistant, tbrown@hcanys.org 388 Broadway, 4th Floor, Albany, NY 12207 Tele: 518-426-8764; Fax: 518-426-8788; Website www.hcanys.org

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ASAP – a publication of the Home Care Association of New York State HONES from p. 1 The budget picture may soon change. The Governor is expected to release his 30-day amendments today, which could result in new appropriations or policies. Those amendments were not posted or available as of ASAP press time. (HCA will immediately inform the membership once these amendments are posted and we’ve had an opportunity to analyze them.) Thursday’s Times Union op-ed presented our most recent estimate of the financial impact as Governor Cuomo’s budget seeks to raise the statewide wage floor to $15 per hour. But, we stressed, this impact – a stunning $1.9 billion for home care, according to newer estimates – is further “troubling” due to the fact that “this new mandate draws focus away from home care needs long left unaddressed,” wrote HCA President Joanne Cunningham. These needs include the “chronic underinvestment of home care’s infrastructure for health information technology and other purposes, as well as the urgent need for reforms to repair an already precarious financial profile,” Ms. Cunningham wrote. She cited our proposed “reimbursement and program fixes” that would “support home care’s needed participation in health system reforms” at a time of financial instability. (The op-ed is posted to http://hca-nys.org/category/hca-inthe-news.) As previously cited, two-thirds of New York’s certified agencies are operating in the red. Meanwhile, all home and community based programs struggle with

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Are you a homecare executive? Then come grow with us!!

HIRING

Dominican Sisters Family Health Service (DSFHS) is seeking an experienced and visionary Chief Operating Officer. The COO is the principal agent of the President/CEO and assumes responsibility for the administration of all DSFHS programs. This is both an operational and strategic role for the agency. Further, he/she will assist the President/CEO in strategic long range planning and Agency evaluation activities to provide for and assure future Agency direction, financial integrity and Agency viability. The successful candidate will possess: • • • • •

Master ’s degree in Health Care Administration, Public Health, Rehabilitative services, MBA or Nursing. Extensive knowledge and competence in community health principles, practice and administration. Evidence of ongoing professional growth which includes ten years of progressively responsible experience in the field of post-acute delivery system, including home care, with five years at executive level. Demonstrated competence of management and strategic planning at the executive level, with supervisory responsibility. Strong interpersonal, organizational and analytical skills with the ability to work in a fast-paced team environment; experience in presenting and reporting to the Board of Directors, and familiarity with New York metro healthcare landscape. (No relocation package available.)

Please e-mail résumé, or curriculum vitae, and cover letter to careers@dsfhs.org or fax to 914-941-4787. We Welcome Diversity: DSFHS is an equal opportunity employer. Regional Program Director (RPD) at VNA Homecare – Albany Area The RPD is responsible for the regional delivery and supervision of care management services provided for enrollees within the Managed Long Term Care Program (MLTC) in the Capital Region, in accordance with agency policy and procedures, and under the direction of the Senior Director of Care Management. The RPD provides leadership and direction to the regional team ensuring that high quality, culturally sensitive and costeffective services and benefits are provided. Bachelor’s degree from an approved school, acceptable to New York State Department of Health. Master’s in Health degree in health-related field preferred. 2 years’ experience as home care nurse in a health agency. Current New York State driver ’s license and automobile insurance. Knowledge and/or experience in long term patient care and chronic disease management. Please send résumés to Mary Cavanagh, Human Resources Manager, VNA Homecare at mcavanagh@477home.org. Director of Performance Improvement and Staff Development at Winthrop University Hospital Home Health Agency Winthrop seeks a Director of Performance Improvement and Staff Development for the CHHA, which services Nassau, Suffolk and Queens. The PI Director is responsible for the quality assessment/assurance program, compliance with DOH regulations and The Joint Commission standards as well as corporate compliance and the educational programs of the agency. Minimum qualifications include: BSN, NYS RN license, two years’ professional nursing experience, two years’ supervisory experience in a CHHA or related program. Knowledge of Performance Improvement and Quality Assurance, as well as a working knowledge of Joint Commission standards and DOH regulations, are a must. Master’s degree preferred. Send résumés to Anne Calvo at acalvo@winthrop.org.

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ASAP – a publication of the Home Care Association of New York State reimbursement issues, billing challenges and increasing financial instability, from the premium payments paid to MLTCs on through to the balance sheets of network home care providers. (See HCA’s recent Risk Factors financial condition report for more key findings). HCA is working on technical budget language to fix these issues and provide much-needed support, consistent with the principles outlined in documents produced for members and the Legislature for last week’s State Advocacy Day. (Please see our document entitled Priority Asks: Position Home Care to Meet the State’s Policy Goals.)

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providers, compromising their basic viability; delays or absence of promised federal matching funds; and the need for investments (such as health information technology) to enable community health providers to ramp up for participation in the new delivery system. The coalition will continue to press these joint messages and requests on behalf of the entire community health sector – including home care, community health centers, behavioral health, pediatric clinics, and others. Wage discussions continue

HCA, Community Health Coalition Press for Investment with Legislative Leaders This week’s budget advocacy specifically included HCA and community health coalition meetings with legislative majority and fiscal committee leader offices. In these meetings, we continued to press the message that state budget allocations must equitably apportion funds to community health providers. HCA and coalition partners provided charts and figures compiled by the Community Health Care Association showing $2 billion-plus in new health/ Medicaid investment for institutional sectors in 2015. Yet, ironically, little-to-no budget investment dollars have been afforded the community based sector, when this sector is otherwise asserted as the fulcrum for health reform and value based care goals. HCA and partners requested proportional community based funding, including a specific allocation to community health providers from the Governor’s proposed new ($200 million) statewide allocation/reallocation of last year’s health care facility transformation funding. We also sought the creation of a new $88.5 million essential community health care provider pool, similar to a pool created last year for the institutional sector. Among the issues we are raising in conjunction with the funding requests are: the state’s reliance on community health providers for its new delivery systems and policies; the financial fragility of these

On the wage issue, specifically, HCA has been working with a broad coalition of association partners to refine our impact calculations. The deliberations have involved several methodologies, leading to a current impact estimate of $1.9 billion for home care, though this may be subject to change as calculations continue. As reported in last week’s ASAP, HCA and several leaders of this provider coalition sent a letter to Governor Cuomo seeking appropriations in the budget to pay for this enormous unfunded mandate; and we are pushing this call for funding at all levels of the Administration and Legislature. As noted in our Times Union op-ed, HCA “has long advocated for improved reimbursement to support home care worker wages and benefits. We agree that staff should be compensated in measure to the valued work they do.” However, “funding for this wage mandate is vital,” and “past history gives us pause” when it comes to add-ons for new federal overtime costs and wage parity. Those reimbursement changes,” Ms. Cunningham wrote, “have either fallen short or been unevenly distributed,” as providers will attest from their experiences with the Quality Incentive/Vital Access Provider Pool (QIVAPP) and other methodologies intended to back-fill unfunded labor costs. Member advocacy critical As HCA noted in an alert to the membership, next week the Legislature is not in session, but that

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doesn’t mean legislators are on break; in fact, next week is the ideal time for you to meet with Assembly and Senate officials face-to-face in their local offices as they take their work back home to the districts. We’ve already heard from some HCA members who are doing this work. They see the incredible stakes for home care in this year’s budget, and so should you. Please take a moment to call the local offices of your Senators and Assembly Members to schedule appointments with them or their staff at their district offices next week. Legislators want to hear your concerns for the future of home care provided to their constituents. Everything you need to say and do is spelled out in a two-page document shared with members during HCA’s State Advocacy Day. This piece, Advocacy Day and Home Care’s “Asks” Made Simple, can be downloaded at http://hca-nys.org/wp-content/uploads/2016/01/HCAQandAAdvocacyDayAsks.pdf. Please schedule these appointments as soon as possible. We’ll be sending follow-up e-mail alerts soon, including options for reaching your legislators using our Legislative Action Center.

Final Rule Requires Medicare Reporting, Returning of Self-Identified Overpayments in 60 Days The U.S. Centers for Medicare and Medicaid Services (CMS) this week issued a final rule that requires certified agencies to report and return overpayments within 60 days after the overpayment was identified, or by the due date of any corresponding cost report, whichever is later. CMS says the rule is meant to support compliance and to protect against improper or fraudulent payments. Health care providers and suppliers have been – and will remain – subject to the statutory requirements found in the Social Security Act and could face potential False Claims liability, civil monetary penalties, and exclusion from federal health care programs for failure to report and return an overpayment. Three major provisions of CMS’s final rule include: 1) clarifications on the meaning of overpayment identification; 2) the required look-back period for overpayment identification; and 3) the methods available for reporting and returning identified overpayments to CMS. The following is a brief summary of each provision. Meaning of Overpayment “Identification” Overpayment must be reported and returned by the later of: 1) 60 days after the date on which the overpayment was identified; or 2) the date any corresponding cost report is due, if applicable. Reporting would occur when a person, “through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount of the overpayment.” Required “Look-back Period” Overpayments must be reported and returned only if identified within six years of the date the overpayment was received. This explanation in the final rule clarifies the timetable for providers and suppliers who identify an overpayment covered by Section 1128J(d) of the Social Security Act. Continued on next page 5

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Continued from previous page How to Report and Return Overpayments Providers and suppliers must use an applicable claims adjustment, credit balance, self-reported refund, or “another appropriate process” to report and return overpayments. A health care provider is considered in compliance if it has reported a self-identified overpayment to either the Self-Referral Disclosure Protocol, managed by CMS; or the Self-Disclosure Protocol, managed by the Office of the Inspector General (OIG). CMS’s final rule (6037-F) can be downloaded at https://s3.amazonaws.com/publicinspection.federalregister.gov/2016-02789.pdf. Additional information is at http://federalregister.gov/a/ 2016-02789. For further information, contact Patrick Conole at (518) 810-0661 or pconole@hcanys.org.

Influenza Declared Prevalent in New York State Unvaccinated Health Care Workers Must Wear Masks On Thursday, state Health Commissioner Dr. Howard Zucker declared influenza prevalent in New York State. With this declaration, home care and other health care workers who are not vaccinated against influenza must now wear surgical or procedure masks in areas where patients are typically present. The mask requirement remains in effect until the Commissioner declares that influenza is no longer prevalent in New York State. According to the state Department of Health (DOH), flu activity in the state is now considered to be widespread, with laboratory-confirmed cases in 44 counties and all boroughs of New York City. So far this season, 817 flu-related hospitalizations have been reported in New York, and no reports of pediatric deaths from flu. Over the last three seasons, there have been 26 pediatric flu deaths in New York and an average of 9,966 flu-related hospitalizations each season. More information, including Frequently Asked Questions, is at http://www.health.ny.gov/diseases/ communicable/influenza/seasonal/providers/prevention_of_influenza_transmission/. Questions about the flu mask requirement can be directed to FluMaskReg@health.ny.gov. Healthcare Personnel Influenza Vaccination Report Since November 2, 2015, the Healthcare Personnel Influenza Vaccination Report has been open for home care and other providers to complete. It is a single, longitudinal report that agencies should be completing as often as necessary to reflect staff changes or changes in vaccination status of staff. The report covers personnel employed by or affiliated with an agency from October 1, 2015 through March 31, 2016. The report must be electronically submitted by May 1, 2016. More information on this report, including a webinar, and resources on influenza are at the above link. Questions about the report should be directed to the DOH Bureau of Immunization at either (518) 473-4437 or immunize@health.ny.gov. 6

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FLSA Funding Update At this week’s state Department of Health (DOH) Managed Care Policy and Planning meeting, DOH provided an update on funding to address some of the Fair Labor Standards Act (FLSA) changes under managed care and fee-for-service. The state already announced last week that it intends to pay $22.8 million to MLTC plans in their March 2 cycle for the period of October 1, 2015 to March 31, 2016. This $22.8 million figure was determined by adding funding to the plans’ rate and adjusting them by risk and region. DOH has received many questions about the distribution of the funds to plans, their home care contractors and the home care aides, from HCA and others, and plans to issue a Question and Answer document in early March. HCA members are urged to send any questions to DOH at FLSA@health.ny.gov (and copy Andrew Koski at akoski@hcanys.org). DOH indicated that, at this time, it does not intend to direct the plan on how to distribute the funds to their home care providers and will leave it to discussion between both plans and providers. HCA has requested a meeting to discuss the distribution and other issues. DOH clarified that home care providers will be required to submit two attestations: one to DOH for its receipt of an FLSA adjustment to Medicaid fee-for-service rates; and one to MLTCs for any FLSA funding they receive from plans. DOH has posted a one-page guidance and attestation forms at http://www.health.ny.gov/health_care/medicaid/redesign/fair_labor_standards_act.htm. Mainstream Medicaid Managed Care Funding DOH also announced that it will provide about $2 million (state and federal funds) to mainstream Medicaid managed care plans for the new FLSA costs faced by their home care providers. These funds will also cover the October 1, 2015 to March 31, 2016 period. The funds will be part of the plans’ fiscal year 2016 October rates (subject to federal approval). HCA suggested that DOH release guidance similar to what it posted on the FLSA funding to MLTC plans. Last week’s ASAP also included information about recently issued Dear Administrator Letters (DALs) for CHHAs, LTHHCPs and Personal Care providers that covered FLSA adjustments for the October 1, 2015 to December 31, 2015 period, and initial rates for 2016 that include an FLSA adjustment. These DALs are all posted on the Health Commerce System.

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Wage Parity Certification Forms Due March 1 The next round of state-required Home Care Worker Wage Parity Law certification forms is due March 1 for CHHAs, LTHHCPs, managed care organizations (MCOs), LHCSAs and other entities that contract with CHHAs, LTHHCPs and/or MCOs who serve New York City, Long Island and Westchester. CHHAs, LTHHCPs, and MCOs must certify prospectively to the state Department of Health (DOH), on an annual basis, their compliance with the Wage Parity Law. This set of certification forms is due to the Department on March 1, 2016 for the March 1, 2016 to February 28, 2017 period. The 2016 certification forms are expected to be posted soon; the 2015 forms are available at http://www.health.ny.gov/health_care/medicaid/redesign/2014-02-12_wage_parity_alert.htm. The CHHA, LTHHCP and MCO forms are sent to DOH at HCWorkerParity@health.state.ny.us. Meanwhile, CHHAs, LTHHCPs and/or MCOs that contract with LHCSAs are required to obtain a written certification on a quarterly basis from the LHCSA or other entity which attests to the LHCSA’s (or other entity’s) compliance with the state’s Home Care Worker Wage Parity Law for defined certification periods and on a prospective basis. The LHCSA form, also due March 1, 2016, covers the period March 1, 2016 through May 31, 2016 and is sent to the CHHA, LTHHCP and/or MCO, not to DOH. This 2016 LHCSA certification form should also be posted soon. In completing the form, HCA recommends adding a date after the signature and noting the certification period on the form. Wage parity levels increase for Long Island and Westchester As mentioned in last week’s ASAP, the Home Care Worker Wage Parity levels will increase starting March 1 for Long Island and Westchester. As of March 1, and continuing through February 28, 2017, the levels for Long Island and Westchester will increase to: a minimum rate of home care aide “total compensation” of $13.22 per hour, consisting of a “base wage” of at least $10 per hour and “supplemental (benefit) wages” of up to $3.22 per hour. Dear Administrator Letters (DAL) announcing these levels and the amounts for New York City (NYC) are at http:// www.health.ny.gov/health_care/medicaid/redesign/mrt_61.htm.Total compensation, base wage and supplemental wages are defined in the DALs. The levels for NYC as of March 1 will be the same as they are for the current March 1, 2015 through February 29, 2016 period. According to the DAL for NYC, the minimum rate of home care aide total compensation will remain at $14.09 per hour, consisting of a base wage of $10 per hour, “additional wages” of up to $1.69 per hour and supplemental (benefit) wages of up to $2.40 per hour. For more information, contact Andrew Koski at (518) 810-0662 or akoski@hcanys.org.

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President Obama Releases 2017 Proposed Budget

DOH Publishes Proposed Hospice Rule

This week, President Obama released his 2017 proposed budget. The various provisions could become part of the broader budget or other Congressional actions. HCA will remain vigilant in monitoring such legislation.

The state Department of Health (DOH) has posted for public comment a rule which will “make state regulations consistent with the federal conditions of participation/rules,” which were revised and implemented on December 3, 2008, as well as consistent with Article 40 of the Public Health Law.

A summary of the health provisions is at http://www.hhs.gov/sites/default/ files/fy2017-budget-in-brief.pdf. Additional information is at https:// www.whitehouse.gov/omb.

The rule is at http://w3.health.state.ny.us/dbspace/ propregs.nsf/4ac9558781006774852569bd00512fda/ 12e4265074a1385985257f550069aa1d?OpenDocument. The rule would make a number of changes to the hospice regulations including:

Some of the Medicare proposals for home care and hospice include: •

•

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Reduce the market basket updates for home health agencies (HHAs) and other post-acute providers by 1.1 percentage points in fiscal year (FY) 2017 and then from FY 2019 through FY 2026. For 2018, the statute requires an update of 1 percent for home health and other post-acute providers. Institute a co-payment for new beneficiaries of $100 per home health episode, starting in 2020. The co-payment will apply only for episodes with five or more visits not preceded by a hospital or inpatient postacute stay. Implement, beginning in 2021, bundled payments for postacute care providers, including home health providers and others. Payments will be bundled for at least half of the

•

Increasing the maximum bed capacity from 8 to 16 beds in a hospice residence.

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Amending the definition of a hospice patient (to a 12-month life expectancy and other revisions) and adding a definition for palliative care.

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Reducing the maximum room capacity from four to two patients.

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Replacing existing sections with new sections on patient rights; eligibility, election, admission and discharge; initial and comprehensive assessment; patient plan of care, interdisciplinary group and coordination of care; quality assessment and performance improvement; infection control; staff and services; contracts; and others.

The proposed rule outlines which proposed changes exceed the federal rules, such as: the governing body’s responsibilities; quality assessment and performance improvement; contract requirements; and infection control. HCA commented on initial drafts of the rule and will be reviewing the rule carefully for further comment.

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total payments for post-acute care providers. •

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Implement a budget-neutral value based purchasing program for several additional provider types, including HHAs, skilled nursing facilities, ambulatory surgical centers, hospital outpatient departments, and community mental health centers beginning in 2018. At least two percent of payments must be tied to the quality and efficiency of care in the first two years of implementation and at least five percent beginning in 2020. Reduce the market basket update for hospice providers by 1.7 percent in 2018, 2019, and 2020. Allow the Department of Health and Human Services (HHS) to implement a hospicespecific market basket by 2012. Allows HHS to make further budget neutral reforms to the hospice payment system.

The budget also includes provisions in the areas of Medicare appeals, program integrity, programs for dual-eligibles, some beneficiary changes, and the Medicaid program, where the President proposes a comprehensive long term care state plan option for up to five states and expanded eligibility under the Community First Choice Option. HCA has published a longer version of this story on our website, where you can find a list of these additional provisions. (Please visit http://hca-nys.org/ general-news/president-obama-releases-2017proposed-budget.) Several of these proposals have been introduced in the past. HCA has long fought efforts to reduce the market-basket update, especially at a time when 70 percent of New York home health agencies are already experiencing negative Medicare margins. Meanwhile, we have joined association partners in firm opposition to copayments, which are a “sick tax” on beneficiaries, harming access to care. HCA will continue our strong engagement with New York’s Congressional Delegation on all of these issues and concerns. 10

Downstate LHCSA Forum: March 29 Please join your LHCSA colleagues, HCA staff and Board Members for a valuable exchange of information, advocacy concerns and recommendations for action at our next Downstate LHCSA Forum on March 29 in New York. Some of the vital issues to be covered include: •

The State Budget

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Quality Incentive/Vital Access Provider Pool (QIVAPP)

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Fair Labor Standards Act (FLSA) rate adjustments for personal care and under Managed Long Term Care

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Upcoming changes in the physician order and Medicaid billing timelines to offer you greater flexibility

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Developments in HIT, technology and quality

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DSRIP

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Additional issues or concerns

More details and registration information are below. Downstate LHCSA Forum March 29, 2016 10 a.m. to 2 p.m. Selfhelp Family Home Care, Inc. 520 Eighth Avenue 5th Floor New York, NY 10018 Download the registration form at: http:// hca-nys.org/wp-content/uploads/2016/02/ HCADownstateLHCSA ForumMarch292016Registration.pdf.

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Overwhelmed by Home Care Finance Issues? Our Senior Financial Managers Summit is a Must-Attend Program It’s just a month into 2016, and you are probably overwhelmed already by the flood of new reimbursement issues and challenges being thrust your way. A proposed multi-billion-dollar minimum wage mandate; five new reimbursement notices (just in the past two weeks) related to the Fair Labor Standards Act; Medicaid and Medicare rebasing; and other ongoing reimbursement challenges are all weighing the tables of home care finance managers. To support you in this big area, we are again offering our popular March program on home care finance, but with a new name: HCA’s Senior Financial Managers Summit. This program is one month away, on March 9, and your finance teams can’t miss it. This program is open to members only, a benefit of your continued membership in HCA, with much to be gained in answers on finance issues. At this program, you’ll gain updates from HCA’s policy staff, Department of Health officials, and expert consultants and analysts on such topics as: •

The state budget, now under negotiation, and its impact on all home care providers.

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Next Steps with the Quality Incentive/Vital Access Provider Pool (QIVAPP) for home care labor costs.

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The newly implemented 2016 Medicare Home Health Prospective Payment System (HHPPS).

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Medicaid rate-setting and recent adjustments for QIVAPP, Wage Parity, and overtime costs.

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Navigating obstacles to prompt payment (at a time when providers report that less than half of Medicaid claims are paid within the prompt-pay timeframe).

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New Data on Medicare Post-Acute Payments.

HCA’s Senior Financial Managers Summit March 9, 2016 9 a.m. to 3:15 p.m. Albany Download the registration form at: http://hca-nys.org/wp-content/uploads/2016/01/2016CFOForum.pdf.

HHCAHPS Data Submission Tool Reopened The Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) Data Submission Tool is now available again on the HHCAHPS website. The tool has been revised to accept ICD-10 codes as the “primary” and “other diagnosis” data elements. The U.S. Centers for Medicare and Medicaid Services (CMS) and the coordination team request that vendors submit at least one data file containing ICD-10 codes in the next few weeks to ensure that you are able to successfully submit with the new code format. The next data submission deadline is April 21, 2016, for the calendar year 2015, fourth quarter data. Questions can be directed to hhcahps@rti.org or (866) 354-0985. 11

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ASAP – a publication of the Home Care Association of New York State

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New Condition Code for Home Health Claims with No Skilled Visits The U.S. Centers for Medicare and Medicaid Services (CMS) this week issued Change Request (CR) 9497 which adds a new condition code for home health claims and other changes. CMS will implement a new condition code 54 “No skilled HH visits in billing period” effective on July 1, 2016. It permits home health claims for subsequent episodes to process even if they do not contain any skilled services. Currently, any home health claim submitted without a skilled visit is automatically returned to the provider (RTP’d). While this is always appropriate for first episode claims in a sequence, or when there is only episode, claims for subsequent episodes are also being RTP’d if they do not include a skilled visit. There may be circumstances which prevent the home health agency (HHA) from delivering the skilled services planned for a subsequent episode, such as an unexpected inpatient admission. Condition code 54 will streamline claims processing in these cases. Claims without skilled visits that are submitted without the new condition code will be returned to the provider. This will allow the HHA to add any accidentally omitted skilled services to the claim; submit the claim as non-covered, if appropriate; or add the new condition code. CMS is also correcting an inadvertent code edit issue related to its termination of HCPCS code G0154 and replacement with two new codes, G0299 and G0300. This change went into effect on January 1, 2016. CMS had instructed the contractors to temporarily deactivate these two edits to prevent Medicare from returning the claims in error. In addition, Medicare systems also use HCPCS code G0154 in the criteria for identifying skilled nursing as the earliest visit when calculating low utilization payment adjustments (LUPA) add-on amounts. Since HHAs can no longer report G0154, skilled nursing visits reported with G0299 or G0300 cannot be used in the calculation. This has resulted in some claims not receiving LUPA add-on amounts or receiving a payment based on the wrong service discipline. The error has been corrected and contractors have been instructed to adjust home health claims. CR 9474 (which can be downloaded at https://www.cms.gov/Regulations-and-Guidance/Guidance/ Transmittals/Downloads/R3457CP.pdf ) also includes a series of routine maintenance revisions to home health billing instructions. For further information, contact the HCA Policy Staff.

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ASAP – a publication of the Home Care Association of New York State

Volume 21, No. 6 February 12, 2016 

DOH Requests LTHHCP Waiver Extension Amid consideration of future program options, the state Department of Health (DOH) has requested extension of the state’s waiver for the LTHHCP from the U.S. Centers for Medicare and Medicaid Services. The current federal waiver authority runs through February 2016. HCA has been working extensively with our Statewide LTHHCP Forum to develop proposals for potential LTHHCP direction in the state’s evolving health care system, including extension of the waiver. HCA met with DOH representatives in late fall to explore basic concepts for LTHHCP functionality under system reforms like the Delivery System Reform Incentive Payment program, managed care and value-based payments. HCA followed with formulation of draft options developed with LTHHCP Forum input at our November meeting and later refined. Conceptually, HCA’s options would seek to better enable MLTC plans and LTHHCPs to work together as well as to provide a basis for LTHHCP viability under the new health care structure. HCA will keep the membership closely apprised of the developments and our progress. For further information, please contact Al Cardillo acardillo@hcanys.org.

More Guidance Coming on TALs, and other Emergency Preparedness Developments Several important new developments in home care emergency preparedness unfolded this week in meetings between HCA, the state Department of Health (DOH) and the New York State Association of Healthcare Providers (HCP). HCA will follow-up with more detail on each of these, but a brief summary is provided below. TALs: The state has scheduled WebEx guidance sessions for home care agencies and hospices on implementation of the Transportation Assistance Levels (TALs) initiative in home care. TALs aim to assist with evacuation transport needs for vulnerable individuals preparatory to emergency. TALs are already in effect for other sectors, and are coming soon for home care. These guidance sessions are planned for two days with repeat sessions on both days: February 25 (10 to 11 a.m. and a repeat at 2 to 3 p.m.); and March 11 (10:30 to 11:30 a.m. and a repeat at 2 to 3 p.m.). Regional Engagement: HCA has been working with DOH and association partners on joint meetings to foster engagement between home care agencies and local emergency managers. The initiative will begin over multiple days and sites in 17 counties of the western New York region, followed by other regions. The goal is to promote mutual awareness of emergency preparedness roles and needs between local home care agencies and emergency managers. Meeting details will be announced shortly. Patient-Family Preparedness: A workgroup of DOH, HCA, HCP and providers agreed to develop a toolkit to be made available to home care agencies and hospices to assist patients and families in their preparedness for emergencies. ISC Training for Social Workers: HCA and DOH are exploring the possibility of allowing Incident Command System (ICS) training as a qualified continuing education unit for Licensed Master Social 13

ASAP – a publication of the Home Care Association of New York State

Volume 21, No. 6 February 12, 2016 

Workers and Licensed Clinical Social Workers. ICS training is offered through the Federal Emergency Management Agency (FEMA) and, if included as continuing education, promises to incentivize critical ICS training in home care and other areas of the continuum. For further information, please contact Al Cardillo at acardillo@hcanys.org, or Alex Blais at ablais@hcanys.org.

Legal Update Stresses HIPAA Implications for Home Care HCA’s legal counsel team at Wilson Elser has prepared a memo regarding investigations by the U.S. Department of Health and Human Services Office for Civil Rights (OCR). These cases have implications for home care providers and their privacy policies under the Health Insurance Portability and Accountability Act (HIPAA). The memo is available at http://hca-nys.org/wp-content/uploads/2016/02/OCRenforcement.pdf. It concerns a recent $240,000 fine imposed on a national in-home provider of respiratory care, infusion therapy and medical equipment. As the OCR Director remarked of that case, “All covered entities, including home health providers,” must ensure that “they have adequate policies and procedures that provide for the reasonable and appropriate safeguarding of protected health information,” or PHI, especially in cases where this information is taken off-site in the delivery of services to individuals at home. The case, and others mentioned in the memo, involved instances of protected health information being kept in an employee’s car and home, as well as security breaches from stolen devices containing electronic private health information (ePHI). As HCA’s legal team sum up in their memo: These OCR enforcement cases underscore a number of things for home care agencies. First, conducting an enterprise-wide risk assessment is not only essential to discover and remedy vulnerabilities to patient PHI, it is also required by HIPAA. Second, home care agencies need to have specific written policies on the removal of PHI and devices and media containing ePHI from their offices and on the proper safeguarding of PHI and ePHI as home care workers use this information to deliver in-home health services. Third, employees of home care agencies need to be trained in the Breach Notification requirements so they know who to inform and how to respond when a breach of PHI or ePHI occurs.

HCA members are encouraged to read the memo, by counsels Frank Fanshawe and Damian Privitera, esqs., for more about the case. Please also consult with your legal counsel regarding compliance with the HIPAA Privacy, Security and Breach Notification Rules.

CMS Proposes Prior Authorization Demo in Five States New York not included The U.S. Centers for Medicare and Medicaid Services (CMS) has proposed a demonstration program this week regarding prior authorization of Medicare home health services in Florida, Texas, Illinois, Michigan, and Massachusetts. These states, with the exception of Massachusetts, are all involved with the U.S. Department of Health and Human Services (HHS) and Department of Justice (DOJ) fraud enforcement program known as H.E.A.T. Continued on next page 14

ASAP – a publication of the Home Care Association of New York State

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Continued from previous page CMS issued the proposal as part of a Paperwork Reduction Act notice in the Federal Register which can be found at https://www.federalregister.gov/articles/2016/02/05/2016-02277/agency-informationcollection-activities-proposed-collection-comment-request. CMS says it would help assure that payments for home health services are appropriate before the claims are paid. As part of this demonstration, CMS would establish a baseline estimate of probable fraud. CMS would then conduct a random sample of home health claims within the five participating states, collecting information from home health agencies, referring physicians, and Medicare beneficiaries selected. This information, along with a summary of the service history of the agency and information about the referring provider and beneficiary, will then be used to estimate the percentage of total payments that are associated with probable fraud, and the percentage of all claims that are associated with probable fraud for Medicare FFS home health services. CMS states that the prior authorization pilot would be similar to the Prior Authorization of Power Mobility Device (PMD) Demonstration, which was implemented in 2012. The pilot would also follow and adopt prior authorization processes that currently exist in other health care programs such as TRICARE, certain state Medicaid programs, and in private insurance. CMS’s proposal is open for public comment until April 5, 2016, and comments can be electronically submitted at http://www.regulations.gov/#!home. HCA plans to submit comments and share our concerns with CMS, especially if this initiative is considered for New York. Home health services are already well targeted by a variety of program integrity initiatives. A prior-authorization program may only further increase access barriers, administrative costs and resource burdens with little or no return. For further information, contact HCA Policy staff.

MLTC Clinical Advisory Group Explores Value Based Payment Models A state Department of Health clinical advisory group convened this week to continue exploring value based payment (VBP) models and options for Managed Long Term Care (MLTC). The advisory group, which includes HCA and HCA provider/MLTC members, examined MLTC-related fiscal and enrollment data, as well as current and potential alignment of quality metrics for MLTC plans, home care agencies and nursing homes. The group also examined potential options for payment bundles and risk-sharing arrangements between managed care, home care, nursing homes and other potential service collaborations. The group’s input will be assimilated into a next round of draft formulations prepared by the Department and the KPMG VBP team for further group discussion. The slide presentation for this week’s meeting can be viewed at http://hca-nys.org/wp-content/uploads/2016/02/MLTCCAGPresentationfinalversion.pdf. HCA invites comments on the information and subject areas included in the slides and will further discuss these next week at HCA’s MLTC Forum in New York City. Comments can be directed to HCA Executive Vice President Al Cardillo at acardillo@hcanys.org. 15

ASAP – a publication of the Home Care Association of New York State

Volume 21, No. 6 February 12, 2016 

FIDA and MLTC Update The state Department of Health (DOH) has posted updated enrollment figures for the Fully Integrated Duals Advantage (FIDA) program. They are at http://www.health.ny.gov/health_care/medicaid/redesign/fida/2016-129_fida_trends.htm. The charts list: estimates of FIDA eligibles by county; enrollment by county; enrollment by plan; enrollment by county and plan; and opt-outs by county. 6,290 individuals were enrolled in FIDA (December 2015) and 61,362 had opted out ( January 2016). Additional information on FIDA is at http://www.health.ny.gov/health_care/medicaid/ redesign/mrt_101.htm. This week’s DOH Managed Care Policy and Planning meeting reported other information on FIDA and managed long term care: •

For February, 140,812 individuals are enrolled in partially capped MLTC plans, 6,034 in FIDA; 5,625 in Medicaid Advantage Plus (MAP); and 5,464 in the Program of AllInclusive Care for the Elderly (PACE).

•

Certificate of Authority Applications will be entertained for any existing MLTC partial cap plan to add a line of business to operate a MAP plan in the New York City and Nassau County regions. Applicants must: 1) also operate and support a FIDA plan; and 2) be in good standing with both New York State and the U.S. Centers for Medicare and Medicaid Services (CMS).

•

Workgroup meetings continue for the Nursing Home Transition and Diversion and Traumatic Brain Injury waiver transition to managed care and a draft of the Waiver Transition plan will be released for public comment on April 1.

•· The Community First Choice Option provides additional federal matching Medicaid funds (above 6 percent) to states to expand and enhance state plan home and communitybased attendant services and supports to individuals in need of long term care for activities of daily living (ADL), instrumental activities of daily living (IADL) and health-related tasks. The plan is for these services to be offered under managed care starting about January 1 2017. •

CMS shared risk adjustment rates with FIDA plans (on average, a 5.7 percent to 10.4 percent increase in the final Medicare A/B standardized rate for calendar year 2016).

•

DOH and CMS held a FIDA educational meeting on January 27; the handouts are at https://www.health.ny.gov/health_care/medicaid/redesign/docs/2016-0127_prov_outreach.pdf.

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ASAP – a publication of the Home Care Association of New York State

Volume 21, No. 6 February 12, 2016 

HCA Provides Memo on NGS Home Care, Hospice Updates New York’s Medicare Administrative Contractor, National Government Services (NGS), held two advisory meetings this week with updates to the home care and hospice provider communities. HCA Vice President Patrick Conole participated in both of these meetings, collecting information and providing feedback to NGS. Given that the home care meeting occurred first, HCA has already circulated a memo on the home care updates. A memo on the hospice updates was finalized today. Both are posted at the links below. Home health memo: http://hca-nys.org/wp-content/uploads/2016/02/ 020916NGSHomeHealthMemo.pdf Hospice memo: http://hca-nys.org/wp-content/uploads/2016/02/ 021216NGSHospiceMtgSummary.pdf The memos provide critical information on Medicare payment and regulatory issues. The home care memo has some specific insights about the “probe and educate” audit process for face-to-face documentation requirements as well as Comprehensive Error Rate Testing (CERT) data findings that assist providers in responding to these reviews and ensuring compliance. The hospice memo similarly reviews CERT findings, medical review and appeals data, hospice audit and reimbursement issues, and more.

GoldSTAMP Committee Plans 2016 Initiatives The GoldSTAMP program State Coordinating Committee met this week to review the program’s status and formulate plans for 2016 initiatives. The GoldSTAMP (“Success Through Assessment, Management and Prevention”) program is a statewide initiative. It brings together partners from the state Department of Health and the University at Albany School of Public Health, as well as hospital, nursing home and home care collaboratives across the state focused on evidenced-based practices for pressure ulcer reduction and prevention. HCA represents home care on the committee, which also includes representatives of hospitals, nursing homes, physicians, the School of Public Health, the Health Department, and IPRO. The committee discussed ongoing work to compile and make available new resources, including a toolkit, to assist all interested providers in incorporating GoldSTAMP. These resources can be viewed at the GoldSTAMP website, which HCA has linked to our home page at www.hca-nys.org. GoldSTAMP is a ready-model. HCA urges providers and health plans to review the GoldSTAMP resources and toolkit, and to consider incorporating this program into your clinical spectrum. The committee plans outreach to increase recognition and consideration of GoldSTAMP opportunities for providers in the Delivery System Reform Incentive Payment (DSRIP) program, Value Based Payment models, managed care and other new state models of coverage and care. Continued on next page 17

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Continued from previous page Ongoing educational and training opportunities are also planned, including specific efforts to increase physician engagement and collaboration in the program. Home care data on pressure-ulcer incidence expected Of interest to home care, the Department expects to soon provide the committee with data on pressure prevalence within home care (similar to its examination of nursing homes and hospital data conducted in 2015). This will include a profile of variances across home care providers and/or regions of the state. HCA has volunteered our staff and provider input as this analysis is put together and interpreted by the Department. For further information, please contact Al Cardillo at acardillo@hcanys.org.

Progress on HCA’s Sepsis Screening Tool and Protocol A first-of-its kind home care sepsis screening tool and protocol – developed by HCA’s sepsis workgroup and quality committee – is being finalized for launch. Sepsis has been the leading source of all-cause hospital readmission for Medicare patients in New York State. It is frequently misperceived as a “hospital infection” issue, when, in fact, over 80 percent of sepsis cases arrive to hospital with sepsis, creating an opportunity area for home care detection and intervention to prevent the catastrophic human and fiscal costs of this condition. HCA and workgroup/committee members have been working on this sepsis early-recognition and intervention tool for home care for the past year. Renowned medical experts, the National Sepsis Alliance, IPRO, the Department of Health and others are also involved. This week, HCA circulated several fine-tune adjustments to the tool as recommended by our participating physicians. HCA is further vetting the tool and seeking endorsement (including opportunities for funding) from the state Department of Health, the Administration and State Legislature. We are also working at the federal level with the National Sepsis Alliance to draw support from the U.S. Centers for Disease Control and Prevention (CDC) as well as resources from other health innovation funds. HCA and the HCA sepsis tool are also core parts of a U.S. Centers for Medicare and Medicaid Services (CMS) early sepsis recognition and intervention grant and development project awarded to IPRO. Please watch for further developments and announcements by HCA on this critical initiative. For further information, please contact Al Cardillo at acardillo@hcanys.org.

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ASAP – a publication of the Home Care Association of New York State

Volume 21, No. 6 February 12, 2016 

Updated FAQs Released for Accountable Health Communities This week, the U.S. Centers for Medicare and Medicaid Services (CMS) posted updated Frequently Asked Questions (FAQs) related to its Accountable Health Communities (AHC) model. The FAQs, along with a fact sheet and funding announcement, are at https://innovation.cms.gov/ initiatives/ahcm/index.html. The new questions cover: necessity to submit a letter of intent; evaluation of sustainability plans; funds for data collection; eligibility of higher education institutions; and others. The AHC model aims to identify and address beneficiaries’ health-related social needs in the following core areas: • • • • •

Housing instability and quality; Food insecurity; Utility needs; Interpersonal violence; and Transportation needs beyond medical transportation.

Applications are due March 31.

Publications •

“New Condition Code for Reporting Home Health Episodes with No Skilled Visits,” by the U.S. Centers for Medicare and Medicaid Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/MM9474.pdf

•

“Revalidation of Medicaid Providers,” (updated) by eMedNY https://www.emedny.org/info/ProviderEnrollment/revalidation/ Revalidation_of_Medicaid_Providers.pptx

•

“Public Health and Health Planning Council 2015 Annual Report” http://www.health.ny.gov/facilities/public_health_and_health_planning_council/meetings/201602-11/docs/annual_report.pdf

For more information, contact Andrew Koski at (518) 810-0662 or akoski@hcanys.org.

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