July 15, 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. 27 July 15, 2016

Gottfried Sends Spot-on Home Care Reimbursement Memo to Helgerson Minimum wage, labor costs demand “uniform and mandatory pass-through” to make providers “whole” In a strong and timely message of support resulting from discussions with HCA, Assembly Health Committee Chairman Richard Gottfried has penned and addressed a spot-on memo to State Medicaid Director Jason Helgerson on the obligations of the state in reimbursing home care and managed long term care plans for minimum wage, overtime, wage parity, workers’ compensation and other labor law requirements.

The memo aligns with HCA’s imperative to the state Department of Health (DOH) for the pass-through of labor reimbursement funds from plans to providers. “I urge that the Department implement a uniform and mandatory pass-through formula that assures that the program, the plans, the providers and the workers are See GOTTFRIED p. 2

HCA Joins Nearly 150 Home Care Representatives and State Association Colleagues for D.C. Policy, Advocacy Summit HCA’s Policy team and provider members headed to Washington, D.C. this week for the first-ever Public Policy Summit and Capitol Hill Advocacy Day, joining state home care associations and representatives from around the nation to bring home care issues to the nation’s capital and engage in collective problem-solving.

The Policy Summit and Advocacy Day program (on July 12-13) was organized by the Council of State Home Care Associations, which collectively includes nearly all 50 state home care associations representing home health care providers. The Council is chaired by Pennsylvania Inside ASAP See D.C. p. 4 Gottfried Sends Spot-on Reimbursement Memo to Helgerson.........1 HCA Joins Colleagues for D.C. Policy, Advocacy Summit...................1 DC Court Issues Order in Favor of HCA in NAHC Litigation................6 Staff Changes, New Appointments in DOH Division of LTC.................6 Get Tips on Wage, Hour, OT Issues at Sept. 8-9 HCA Retreat.............7 QIVAPP Amounts Announced for 2014-15............................................7 Sponsor: First-ever Women’s Healthcare Leadership Summit..........10 Directive Issued on “Immediate” Personal Care Needs...................11 New Program: Blueprint for OASIS Accuracy – OASIS-C2 Data Set..12 HHS Proposes Changes to Medicare Appeal Process......................12 Palliative Care Funding for Adults and their Caregivers....................13 In Memoriam: Connie Raffa, July 7, 2016............................................14 FIDA Data, Resources Posted..............................................................15 Quality of Patient Care Star Ratings Preview Reports Available......15 PHHPC Committee Review Agenda Posted......................................16 New Hospice Report Available on 7/17 in CASPER........................16 Ransomware Fact Sheet Posted.........................................................16 National Health Expenditure Projections: 2015-2025.......................17 Publications......................................................................................17

Reminder Reminder: HCA is on a biweekly summer ASAP schedule. Our next edition will be published on July 29. We will keep you posted by e-mail about any breaking updates.

Helping New Yorkers Feel Right At Home

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GOTTFRIED from p. 1 made whole,” Assemblyman Gottfried writes, consistent with HCA’s assertion that funding for labor mandates (including the minimum wage hike) must be sufficient, timely and direct in reaching employers.

The July 11 memorandum grew out of post-budget legislative discussions, specifically HCA’s drafting of legislation for adequate home care cost coverage of labor mandates under fee-for-service and managed care (not just for minimum wage, but also the federal overtime changes, wage parity, workers’ compensation and other labor costs). That legislation worked off of language adopted in the state budget (and originating with budget language provided by HCA and introduced by the Assembly) mandating reimbursement adequacy and actuarially sound rates to comply with these state laws and related agency cost needs.

The post-budget language was introduced by Senate Health Committee Chairman Kemp Hannon (S.8072) and passed the Senate. In tandem with the Senate bill, Assemblyman Gottfried offered to convey the same issues and concerns with a direct memorandum to the Cuomo Administration.

Assemblyman Gottfried’s memo references state budget language, originated by HCA, which intended to adequately fund Medicaid expenditures. He expresses concerns that the Department’s chosen approach to implement the funding conflicts with statute by putting the flow of payments at risk for the home care workforce – and, by extension, poses undue financial liability for home care providers.

“It has been reported to me that the Department has proposed that managed long term care plans should be given free rein to negotiate adjustments in reimbursements for the minimum wage increase with home care agencies,” he writes. “I am concerned that the terms of such negotiation would unavoidably put at risk staffing levels, hours of care, or service eligibilities to reduce spending to free up money for minimum wage compliance.”

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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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Continued from previous page He adds: “To enable such a negotiation would violate the same section of law which requires the rates to ‘consider costs borne by the managed care program to ensure … quality of care’.”

Asserting that “the Medicaid rate must be sufficient for the workers’ wages and administrative and general cost factors essential to the delivery of care,” Assemblyman Gottfried points to four sections of law and/or cost areas that “must be supported,” including: the Wage Parity Law, the minimum wage statute, the Workers’ Compensation Law, and the Fair Labor Standards Act rule changes for employee overtime and mandatory benefits.

Regarding concerns that the state is allowing “flexibility” for plans to pass-through funds to providers, Assemblyman Gottfried adds: “I cannot imagine what flexibility is needed. If the rate is actuarially sound … then sufficient funds should simply flow to a sufficient workforce.”

HCA applauds Assemblyman Gottfried’s stand on these issues, along with Senator’ Hannon’s sponsorship of related legislation in his chamber, both of which add an important voice to the HCA/DOH/ Stakeholder discussions over minimum wage and other labor rate adjustments.

As announced in an alert this week to members (and reported on p. 7 of this week’s ASAP), the state has announced Quality Incentive Vital Access Provider Pool fund distributions for 2014-15 to managed care and downstream providers for New York City Wage Parity Law costs. These amounts will be released to the MLTC plans on July 20 and the plans will have 30 days (until August 19) to distribute the funds to their eligible home care partners. In cases where home care providers owe money, they will have 30 days to repay the plans. A separate process for determining 2015-16 distributions is now underway, with desk audits being conducted by IPRO for agencies not found eligible for 2014-15 QIVAPP monies. (See related p. 7 story for more information on this process and HCA’s advocacy on behalf of providers.)

On the minimum wage front, a stakeholder meeting with the Department was scheduled for early July but HCA has learned that this meeting will not be held. HCA is continuing our efforts to secure broad-based support from all home care stakeholders to press for a simple, straightforward and complete pass-through of funds to providers to cover the costs of minimum wage. HCA has convened a meeting of our collaborative partners to ensure a coordinated strategy with minimum wage.

For more information, please contact a member of the HCA Policy staff.

Learn more. Visit: www.bringthevothomeny.org.

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

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D.C. from p. 1 Homecare Association CEO Vicki Hoak and HCA’s President Joanne Cunningham is a Member of the Council’s Board of Directors.

HCA and other state associations invited our provider members to attend this two-part program, which included a Summit of policy discussions, presentations from federal bureaus on regulatory and payment issues, and insights from D.C. political insiders, as well as a Capitol Hill Advocacy Day of visits with lawmakers.

Nearly 150 participants from around the nation converged at the nation’s capital, including the following HCA members: Bassett Healthcare Network: At Home Care CEO Laurie Neander (an HCA Board Member); VNA Home Care CFO June Castle (an HCA Board Member); Mary Nicholson, Director of Compliance at Lifetime Care; Lauren Huber, Director of Quality/ Education at Montefiore Medical Center Home Health Agency; Andrew Segal, Director of External Affairs and Government Relations at Visiting Nurse Service of New York (VNSNY); and Sue Caputo, Senior Vice President, Business Development, VNSNY. They were accompanied by HCA President Joanne Cunningham, HCA Executive Vice President Al Cardillo, HCA Director of Public Policy Alex Blais, and our federal government-affairs representative Brett Heimov of Envision Strategy.

The HCA and member team met with Representatives in Congress

HCA’s Policy Team and HCA members meet with Rep. Joseph Crowley (fourth from right).

and/or the offices of Reps. Eliot Engel, Louise Slaughter, Joseph Crowley and Chris Gibson. They also met with the offices of U.S. Senators Charles Schumer and Kirsten Gillibrand.

HCA discussed at length several top-tier issues with the Congressional Delegation, including: the need for relief from Medicare home health rebasing cuts; the onerous physician faceto-face mandate for authorization of home care services; other payment issues, like the recently proposed pre-claim review rule; and the need for Congress to continue opposing copayments for home health beneficiaries.

HCA’s briefing papers on these issues are available on our website at http://hca-nys.org/publications/briefing-papersfederal-home-health-policy-summit-and-capitol-hill-advocacyday. We encourage you to read and share these documents with any of your Congressional contacts.

“New York’s home care system is in a uniquely precarious state,” said Ms. Cunningham in an HCA press release about the Summit and Advocacy Day. “While the federal government seeks to normalize Medicare margins through a series of rebasing cuts, 4

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we have legitimate objections to the methods and data samples used to justify such deep payment reductions.”

As part of its proposed Home Health Prospective Payment System (HHPPS) rule, the U.S. Centers for Medicare and Medicaid Services (CMS) is calling for another round of so-called “rebasing” cuts: $180 million in 2017. This follows $700 million in total cuts since 2014.

HCA has taken issue with the selection of data used to justify rebasing, as it is incomplete, outdated and fails to recognize regional variations in outcomes, especially for states like New York suffering from extreme financial losses due to the cuts.

Another continued target of HCA and home care association advocacy is the disastrous Medicare face-toface rule.

“Repeatedly, we’ve called for Congressional action to overturn or amend this onerous and duplicative requirement,” Ms. Cunningham said. “While the face-to-face requirement seeks even greater physician involvement, the arcane, duplicative and unnecessarily complex compliance rules are virtually designed for physician and provider error. The effect is disastrous: claims are denied on the basis of technicalities, administrative costs have exploded for providers having to chase down paperwork, and home care agencies remain financially liable for documentation that is largely outside their control.”

Since the face-to-face rule was initiated in 2010, HCA has been a leader in pressing for Congressional intervention to urge a CMS fix to its rule. We have both written and additionally sought legislation to streamline the face-to-face process by allowing physicians to simply document their face-to-face encounter with patients on long-used physician-order forms, rather than through a separate documentation process.

CMS has initiated a campaign called “probe-and-educate” audits, in which the contractors are auditing claims, denying those claims that don’t meet the rigorous face-to-face standards, and conferencing with providers individually on the reasons why the claim was denied.

Cunningham added: “While we welcome additional training and education on federal requirements – and have even coordinated these training sessions with Medicare contractors, physicians and hospitals – the very fact that CMS needs to conduct probe-and-educate audits suggests that the rule is not practical or sensible in its current form. CMS and home care provider resources could be better put to use in other areas, including a more direct target on areas where risk of fraud is greatest, not all providers.”

The Council and its associations also called on Congress to continue opposing a copayment charged to Medicare home health beneficiaries. The copayment idea has been put on the table several times during recent deficit-reduction talks as a way to raise revenue. But copayments are an unjust cost imposed on beneficiaries who may choose to forgo home health services altogether rather than pay the cost, possibly ending up in the hospital or other costlier settings if their conditions are not treated at home.

HCA appreciates our members for participating in this unique state-association-led event and for explaining to Congress their experiences with Medicare cuts and mandates. We also appreciate the time taken by the Congressional Delegation to hear our concerns. HCA will continue to press these issues through the ongoing engagement of our executive and government-relations teams.

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DC Superior Court Issues Order in Favor of HCA in NAHC Litigation In January 2016, HCA commenced litigation against the National Association for Home Care and Hospice (NAHC), NAHC’s Board Chair, its President and CEO, and outside legal counsel, for violating the NAHC bylaws when they illegally attempted in October 2015 to remove HCA’s representatives – HCA President Joanne Cunningham and HCA Member (and HCA Board Member) Laurie Neander – from the NAHC Board of Directors.

HCA just prevailed overwhelmingly in the lawsuit. In a June 23, 2016 order (available at http://hca-nys.org/wp-content/uploads/2016/07/ HCANAHCorderofjudgment.pdf ), the Superior Court of the District of Columbia ruled in HCA’s favor, declaring that: the October 2015 action (as well as a subsequent June 2016 Board action) of the Defendants violated NAHC’s bylaws and were invalid; both Ms. Cunningham and Ms. Neander were never removed from the Board; and Ms. Cunningham and Ms. Neander continued to serve as Board members of NAHC with uninterrupted service following Defendants’ invalid actions.

The Superior Court also ordered NAHC to pay HCA’s legal fees.

The Superior Court will be reviewing HCA’s invoices for legal fees and determine the exact amount NAHC must pay HCA. Both Ms. Cunningham and Ms. Neander resigned from the NAHC Board of Directors on July 6, 2016. They both resigned because it became apparent during the course of the lawsuit that, although certain members of the NAHC Board and management remain dedicated to furthering the interests of NAHC, other members of the NAHC Board and management appeared focused on advancing their personal interests ahead of NAHC’s interests. Ms. Cunningham and Ms. Neander could no longer work and fulfill their Board duties in that type of environment.

HCA has been reasonable in its approach throughout. It made numerous attempts to informally resolve its concerns with NAHC before it commenced the lawsuit, but NAHC had refused to engage or respond to HCA’s outreach. This forced HCA to commence the lawsuit and seek its relief through the Superior Court.

The Superior Court’s order did not address HCA’s count in the lawsuit concerning wrongful interference with business relations.

That count is still pending. HCA will continue to pursue relief on that count.

For further questions, please contact Joanne Cunningham at jcunningham@hcanys.org.

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Staff Changes, New Appointments in DOH Division of LTC Andrew Segal, Director of External Affairs and Government Relations at Visiting Nurse Service of New York (VNSNY), has been appointed to serve as Director of Long Term Care in the Office of Health Insurance Programs (OHIP) with the state Department of Health, and Mark Kissinger will be moving from the post to serve as Special Assistant to the Commissioner for Long Term Care.

Mr. Segal has worked closely with HCA in his current role as Director of External Affairs and Government Relations at VNSNY. He formerly served as the Director of MLTC Product Management for VNSNY CHOICE Health Plans as well as Chief of Staff to the President and CEO of the Visiting Nurse Service of New York.

HCA congratulates Mr. Segal on this significant role at the Department and we look forward to continue engaging with him now in his new capacity. HCA congratulates and looks forward to our continued working relationship with Mr. Kissinger as he reportedly will be leading several efforts related to long term care redesign in his new capacity as Special Assistant to the Commissioner. HCA thanks Mr. Kissinger for his work with us and the home care, hospice and MLTC communities during his service as Long Term Care Director.

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Get Tips on Wage, Hour, OT Issues and Other Finance Updates for All Home Care Agencies at Sept. 8-9 HCA Retreat An upcoming minimum wage hike ... FLSA costs ... newly announced QIVAPP distributions ... these and other wage, hour and overtime policy changes are weighing on the minds of home care agencies and managed care plans across New York State.

HCA has been working to advocate and keep you up-to-date on fast-moving developments with these issues, including through our education programs, like the upcoming HCA Senior and Financial Managers Retreat coming up on September 8-9 at the Mohonk Mountain House in New Paltz.

The program is designed for CFOs and other finance managers, as well as COOs, CEOs and other executives involved in your organization’s budgeting and financial strategic positioning.

Labor Law Experts from Hodgson Russ One session at the Retreat will be led by labor law experts Peter Godfrey, John Godwin, and Emina Poricanin of Hodgson Russ, LLP. They’ll examine and describe the most pressing changes for wages, overtime and hours, including: court decisions impacting live-in workers; the elimination of the companionship exemption and resulting struggles with compensation rules; the implications of wage and hour class-action litigation; and a recently implemented overtime rule affecting overtime-exempt employees.

The session will close with practical tips to mitigate exposure to wage and hour liability while staying in compliance with federal and state compensation laws and regulations.

This is just one of the sessions scheduled, among several, focusing on every dynamic affecting your bottom line. Our Retreat has something for every agency and every finance leader, from every area of the state, providing can’t-miss insights on: Medicare and Medicaid policies, reimbursement issues and updates across all payors, labor law implications, workforce development needs, value-based payments, strategic positioning and more. Please register today at the links below and share with your entire finance and leadership team.

Brochure: http://hca-nys.org/wp-content/uploads/2016/06/SrFinanceRetreatBrochure2016.pdf Online registration: https://www.eventville.com/catalog/eventregistration1.asp?eventid=1011953

QIVAPP Amounts Announced for 2014-15 2015-16 QIVAPP eligibility criteria outlined; update on FLSA funds As mentioned in a July 7 HCA Alert, the state Department of Health (DOH) has finalized the reconciled amounts under the Quality Incentive Vital Access Provider Pool (QIVAPP) program for April 1, 2014 to March 31, 2015. The program applies to “qualified” New York City providers subject to the state Home Care Worker Wage Parity Law. These amounts will be released to the MLTC plans on July 20 and the plans will have 30 days (until August 19) to distribute the funds to their eligible home care partners. In cases where home care providers owe money, they will have 30 days to repay the plans.

Continued on next page 7

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Continued from previous page HCA has obtained a list of the reconciled QIVAPP amounts by each MLTC plan for their home care contractors. The data is presented by plan name, with personal care and home health aide distribution information for each provider.

HCA has extracted and sorted the data into a master spreadsheet by home care provider name and can send you an Excel report with the amounts corresponding to your agency. If you are an HCA member and would like this report, please e-mail HCA’s Communications Director Roger Noyes at rnoyes@hcanys.org. Please use the subject line “QIVAPP.” HCA has already received several of these requests which we processed to members throughout the past week.

Please note that the spreadsheet may take more than a day to be prepared and double-checked for you, depending on the number of inquiries we continue to receive.

Important: Please also note that the information in the spreadsheet we prepare may not be complete, given idiosyncrasies in the way that your organization’s name is labelled by DOH, including some providers who have multiple versions of their names listed. HCA will attempt to compile information for all variations of your agency name in the report. If, for instance, a plan distribution amount seems missing, please notify us and we will double-check our data set.

2015-16 QIVAPP Eligibility As announced in last week’s HCA Alert, DOH has released a “Dear Agency Administrator” letter about funding for the QIVAPP program for April 1, 2015 to March 31, 2016.

The guidance is at http://hca-nys.org/wp-content/uploads/2016/07/DAL_QIVAPP_2015-16.pdf.

According to the letter, those agencies found eligible for QIVAPP for the prior period (April 1, 2014 to March 31, 2015) will not need to provide additional documentation in order to receive QIVAPP monies for 2015-16.

Those not found eligible for the 2014-15 period will have an opportunity to establish their eligibility for the 201516 period through a desk audit that IPRO will conduct with LHCSAs contracted with managed care plans.

IPRO reviews will be conducted this month. They will consist of IPRO e-mailing a review packet to the agency administrator of record, including instructions about the documentation being requested and a July 21 deadline. While DOH has indicated no extensions will be granted, we have requested additional time when home care providers were not notified or notified late by IPRO of this opportunity to apply for 2015-16 QIVAPP monies. DOH anticipates that the desk audits will be completed by August 12, 2016.

IPRO will report to DOH any agency that does not respond to this request for information, or any agency that is not able to demonstrate compliance with program requirements, including: 

Paying a base hourly rate of at least $18.50 (as of April 1, 2015);

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Offering a specialty training program that exceeds the DOH requirement; Continued on next page 8

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Continued from previous page 

Providing evidence of a written, implemented, and currently active quality assurance program;

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Providing comprehensive health coverage which must equal or exceed the DOH sample QIPP benefit, provided at http:// www.health.ny.gov/health_care/ medicaid/redesign/docs/2014-06-13_benefits_overview_qivapp_application_attach2.pdf;

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Demonstrating that at least 30 percent of their total New York City workforce is enrolled in the health benefits coverage.

HCA has also learned that the federal share will be the same as the state share amount ($22.8 million) and plans will receive the same amount that they received under the state share (see http:/ /www.health.ny.gov/health_care/ medicaid/redesign/2016/2016-0311_flsa_add_info.htm). It is expected that plans will pass through these funds to their home care contractors similarly to how they passed on the state funds.

HCA advocacy on these and other rates As reported on page 1, Assembly Health Committee Chairman Richard Gottfried has sent a strongly worded memo to state Medicaid Director Jason Helgerson about the distribution issues with these and other rate add-ons, including the minimum wage hike appropriations.

DOH staff will review the IPRO reports, make the final determination regarding eligibility for the 2015-16 period, and determine next steps, which may include on-site review.

HCA had submitted to DOH a number of recommended QIVAPP changes for the 2015-16 period, including an opportunity for those LHCSAs not found eligible in 2014-15 to establish their eligibility for 2015-16. We also sought a change allowing comprehensive health coverage to be met as of April 1, 2015. DOH agreed to both terms. We had also taken issue with the definition of “comprehensive health coverage” and the “30 percent threshold” requirement outlined above and asked that they be revised.

The memo, prompted by HCA, reflects many of our core concerns about the need for direct funding of all statutory labor mandates for home care agencies, including the FLSA changes, wage parity, Workers’ Compensation and minimum wage. It adds a strong voice to our call for improvements to DOH’s distribution methods going forward and we will continue our call for direct, timely and unencumbered payment flows during ongoing discussions of the rate add-on process, including stakeholder meetings, now underway, for discussing the distributions of minimum wage-related funds.

FLSA DOH has also advised us that the state Division of Budget approved the federal share of funding to compensate providers for the Fair Labor Standards Act (FLSA) changes for October 13, 2015 to March 31, 2016. DOH is working to load the funding into rates for MLTC plans. Once DOH confirms the payment date, it will notify plans of payment and the FLSA amount. The plans will then have 30 days to pass through these monies to their contracted home care providers.

For more information, contact Alex Blais at (518) 810-0658 or ablais@hcanys.org, or Andrew Koski at (518) 810-0662 or akoski@hcanys.org.

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

Invitation to Sponsor: First-ever W omen’ Women’ omen’ss Healthcare Leadership Summit HCA is offering several sponsorship opportunities for organizations that want to support — and gain exposure at — e HCA’s first-ever Women’ omen’ss Healthcar Healthcare Leadership Summit on September 28 to 29 in Saratoga. What better or more positive way is there to promote your brand than at this important leadership program for women in healthcare?

The summit will be held at the Excelsior Springs at the Courtyard Marriott, 47 Excelsior Avenue, Saratoga Springs, NY. A full brochure for this summit is coming soon soon. The program aims to empower, inspire and connect women in the field of health care to celebrate current successes, tackle the challenges and sharpen their leadership prowess.

With change comes opportunity, so in this unprecedented era of change in the health care industry, there is an opportunity to foster greater balance in gender diversity within our industry’s leadership.

The issues and necessary skills required of women leaders are comparable to that of their male counterparts; however, the context and conditions for women leaders can be uniquely challenging.

Please support this exciting new program.

Download the brochure today: http://hca-nys.org/wp-content/uploads/ 2016/06/Womens-Summit-SponsorshipBrochure.pdf 10

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Directive Issued on “Immediate” Personal Care Needs The state Department of Health (DOH) has posted an Administrative Directive (ADM) instructing local departments of social services (LDSSs) about a 2015 state law that requires expedited Medicaid eligibility determinations for Medicaid applicants who have an immediate need for Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS), and expedited procedures for determining PCS or CDPAS eligibility for Medicaid recipients with an immediate need for services.

The ADM is at http://www.health.ny.gov/health_care/medicaid/publications/pub2016adm.htm.

The law also requires that the final Medicaid eligibility determination be made within seven days of the date of a complete Medicaid application. For Medicaid applicants with immediate needs for PCS or CDPAS who are determined eligible for Medicaid and PCS or CDPAS, such services are required to be provided pending the individual’s enrollment in a managed care plan or managed long-term care plan.

Medicaid Applicants A Medicaid applicant with an immediate need for PCS or CDPAS may be either an individual not currently authorized for any type of Medicaid coverage, or an individual authorized only for community-based coverage that does not include coverage for long-term care services such as personal care services.

These individuals must provide the district with a physician’s order for PCS or CDPA and a signed attestation, on a form required by the Department, attesting that: they have an immediate need for PCS or CDPAS; they have no informal caregivers; they are not receiving needed assistance from a home care services agency; they have no third party insurance or Medicare benefits available to pay for needed assistance; and adaptive or specialized equipment or supplies are not in use to meet, or cannot meet, their need for assistance.

The district is required to determine whether the Medicaid applicant has submitted a complete Medicaid application as soon as possible, but no later than four calendar days after receipt of a Medicaid application or request for an increase in Medicaid coverage to include community-based long-term care, together with the physician’s order and signed attestation of immediate need.

Once a complete Medicaid application is received, the district must determine Medicaid eligibility within seven calendar days and send notification to the applicant. In addition, as soon as possible but no later than twelve calendar days after receipt of a complete Medicaid application, the district must: obtain or complete a social assessment and nursing assessment; determine whether the Medicaid applicant, if deemed eligible for Medicaid, would be eligible for PCS or CDPAS; and, if eligible, determine the amount and duration of services that would be authorized.

The procedures for individuals who already have Medicaid are similar. They have to submit a physician’s order for PCS or CDPAs and a signed attestation, attesting that they have no informal caregivers; they are not receiving needed assistance from a home care services agency; they have no third party insurance or Medicare benefits available to pay for needed assistance; and adaptive or specialized equipment or supplies are not in use to meet, or cannot meet, their need for assistance.

The LDSS timeframes for Medicaid recipients are outlined in the ADM, along with a sample notice to give applicants and recipients.

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

Volume 21, No. 27 July 15, 2016 

New Program: Blueprint for OASIS Accuracy – OASIS-C2 Data Set Register by Oct. 6 deadline!  

October 26 and 27 (Workshop), from 8 a.m. to 4 p.m.

October 28 (COS-C Exam), from 9 to 11:30 a.m.

This two-day OASIS C-2 Data Collection Rules and Guidance workshop includes an optional Certificate for OASIS Specialist-Clinical (COS-C) exam at the same location. Experience the comprehensive and nationally acclaimed workshop to confidently teach, audit and collect OASIS C-2 items accurately. Through guided, expert instruction, and participation in problem-solving discussions and application scenarios, achieve mastery of the OASIS items, conventions, and the latest data collection rules.

The Certificate for OASIS Specialist-clinical (COS-C) Exam is a voluntary certificate examination for those interested in demonstrating and establishing their expertise and commitment to OASIS data accuracy.

Candidates who successfully pass the examination, conveniently offered the day after the workshop and at the same location, are awarded the COS-C designation.

Individuals may register for the workshop, the exam or both. 

Workshop/Exam Location: Visiting Nurse Service of NY, 1250 Broadway, 7th Floor, Meeting Rooms 7A/B/C, New York, NY 10001

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Hotel Accommodations: Hampton Inn Manhattan, Madison Square Garden Area, 116 West 31st Street, New York, NY 10001

Register online at: https://www.eventville.com/catalog/eventregistration1.asp?eventid=1011960.

Get the brochure: http://hca-nys.org/wp-content/uploads/2016/07/Blueprint-for-OASIS-NYC-2016.pdf.

HHS Proposes Changes to Medicare Appeal Process The U.S. Department of Health and Human Services (HHS) has posted a proposed rule that would make a number of changes to the Medicare appeals process.

The proposed rule is at https://www.gpo.gov/fdsys/pkg/FR-2016-07-05/pdf/2016-15192.pdf.

As mentioned in the July 1 ASAP, the changes are being made in part to reduce a backlog of over 800,000 appeals awaiting adjudication at the administrative law judge (ALJ) level.

Some of the changes would: 

Make selective Medicare Appeals Council (“Council”) decisions precedential or binding on the U.S. Centers for Medicare and Medicaid Services (CMS) and its contractors such that it must be followed in future determinations and appeals; and

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Allow attorney adjudicators (those employed by the Office of Medicare Hearings and Appeals with knowledge of Medicare coverage and payment law and guidance) to issue: decisions when a decision 12

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can be issued without an ALJ conducting a hearing; dismissals when an appellant withdraws a request for an ALJ hearing; and remands for information that can only be provided by CMS or its contractors or at the direction of the Council. 

Change the “amount in controversy” (AIC) calculation ($150 in 2016) for certain claim appeals to generally use the Medicare allowable amount rather than the billed amount for most Part B claims.



Add information required from providers who are requesting a hearing regarding statistical sampling and extrapolations that were used in making an overpayment determination.

In addition to these proposed reforms, HHS also intends to reduce the appeals backlog by: 

Requesting new resources to invest at all levels of appeal to increase adjudication capacity and implement new strategies to alleviate the current backlog; and



Proposing legislative reforms that provide additional funding and new authorities to address the volume of appeals.

More information is also at http://www.hhs.gov/dab/medicare-appeals-nprm-fact-sheet-june2016.pdf.

Palliative Care Funding for Adults with Advanced Illnesses and their Caregivers The Patient Centered Outcomes Research Institute (PCORI) has posted a notice of an upcoming funding opportunity related to palliative care research.

PCORI seeks to fund multiple, large, multi-site, community-based comparative effectiveness research (CER) studies. Institutions and consortia with expertise in clinical CER or patient-centered outcomes research (PCOR) and community-based palliative care delivery are invited to apply for the funds to be announced in mid-August 2016.

The CER studies are sought to generate evidence to: a) support care planning for adult patients with advanced illnesses over time that is consistent with the goals and preferences of adult patients and their caregivers; and b) support the delivery of coordinated, community-based palliative care that effectively implements those care plans.

The deadlines will be September 14, 2016 for letters of intent, and December 19, 2016 for applications.

More information is at http://www.pcori.org/funding-opportunities/announcement/communitybased-palliative-care-delivery-adult-patients-advanced.

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

Volume 21, No. 27 July 15, 2016 

In Memoriam: Connie Raffa, July 7, 2016 HCA was very saddened to learn last week about the passing of a friend and member of the HCA extended family, health care legal expert Connie Raffa, following a battle with cancer. She passed on July 7.

Ms. Raffa spent nearly four decades practicing law, first in the state Office of Prosecution for Special Narcotics, from 1973 to 1976; then as New York County Assistant District Attorney from 1978 to 1980 under Robert Morgenthau; and also as a U.S. government lawyer.

She worked for the U.S. Department of Health and Human Services (HHS) for 15 years as a senior trial attorney and assistant regional counsel in the agency’s Office of General Counsel. She represented HHS before federal district and appeals courts and in administrative hearings. As a prosecutor, Connie was appointed special assistant U.S. attorney in the Eastern, Southern, and Northern Districts of New York and the District of Puerto Rico.

She joined Arent Fox, LLP in 1995 and founded its New York Health Care group, advising home health agencies, hospices, physician groups, state health associations, and palliative care programs on regulatory and reimbursement issues, fraud and abuse investigations, and sanctions. Ms. Raffa worked tirelessly, providing vital pro-bono legal advice.

Connie Raffa was a great friend to the home care community and a staunch advocate whom HCA relied on enormously for expertise about legal and compliance issues, payment integrity initiatives, audits, and best-practices. Her presentations at many of our education programs always provided unmatched insight, expertise and clarity about some of the most complex issues facing home care and hospice providers.

We at HCA will greatly miss her wisdom, her tenacity, and her friendship.

A remembrance is posted by her firm, Arent Fox, at the following link: http://www.arentfox.com/ newsroom/press-releases/remembering-connie-raffa#.V4fPkfkrK70.

In lieu of flowers, contributions may be made in her memory to the American Cancer Society or Hospice Care Network.

We at HCA extend our condolences to Connie Raffa’s family, her close colleagues, and the extended home care community who knew her so well.

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Volume 21, No. 27 July 15, 2016 

FIDA Data, Resources Posted The state Department of Health (DOH) has posted updated information about the Fully Integrated Duals Advantage (FIDA) program.

The data is at https://www.health.ny.gov/health_care/medicaid/redesign/fida/docs/2016-0706_fida_trends.pdf.

The information includes: FIDA eligibles who are enrolled in an MLTC or FIDA plan; FIDA enrollment by county; FIDA enrollment by plan; FIDA enrollment by plan and county; FIDA opt-outs by county; FIDA enrollment by age and gender; number of people who transferred from one FIDA to another FIDA plan since January 2016; and other data.

FIDA Resources 

NY Medicaid Choice: 1-855-600-FIDA (1-855-600-3432), available Monday to Friday, 8:30 a.m. to 8 p.m., and Saturday from 10 a.m. to 6 p.m. (www.nymedicaidchoice.com)



ICAN (Independent Consumer Advocacy Network), which is the Ombudsman program for FIDA, MLTC and Long Term Care, is available at 1-844-614-8800, Monday to Friday, 8 a.m. to 8 p.m. (www.icannys.org).

Quality of Patient Care Star Ratings Preview Reports Available The U.S. Centers for Medicare and Medicaid Services (CMS) has announced that, due to the July 4 holiday, the Quality of Patient Care Star Ratings Preview Reports were made available in CASPER (Certification and Survey Provider Enhanced Reports) folders the week of July 5.

These reports contain data that will be publicly reported on the Home Health Compare website in October 2016. Starting this quarter, the preview report includes additional information about the rating and how the results shown on the scorecard can be used by agencies for quality improvement.

The deadline to submit a request to have the star rating data suppressed is July 25, 2016. Certified Home Health Agencies should follow the directions laid out in the Preview Reports to submit a suppression request.

The Quality of Patient Care Star Rating is based on Outcome and Assessment Information Set (OASIS) assessments and Medicare claims data. Provider preview reports showing the Quality of Patient Care Star Ratings and rating calculations for each agency are distributed to agencies approximately 3.5 months before the ratings are published on Home Health Compare. Agencies have several weeks to review the data. Agencies can also request that CMS review their rating if they can submit evidence that the data used to calculate the measures were inaccurate or incomplete to the extent that their star rating was affected.

Any questions about these reports can be directed to HomeHealthQualityQuestions@cms.hhs.gov.

Additional information is at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessmentinstruments/HomeHealthQualityInits/HHQIHomeHealthStarRatings.html.

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PHHPC Committee Review Agenda Posted The state Department of Health (DOH) has posted the agenda for the July 21 meeting of the Public Health and Health Planning Council (PHHPC) Committee on Establishment and Project Review.

The agenda and supporting documents are at http:// www.health.ny.gov/facilities/ public_health_and_health_planning_council/meetings/ 2016-07-21/.

The agenda includes the following applications: 1. Five downstate LHCSAs for changes in ownership; 2. One CHHA to purchase the assets of another CHHA; and 3. A CHHA to change its corporate member.

The next meeting of the full PHHPC is on August 4.

New Hospice Report Available on 7/17 in CASPER The U.S. Centers for Medicare and Medicaid Services (CMS) has announced that a new report, Hospice Timeliness Compliance Threshold Report, will be available starting July 17, 2016 to hospice providers in the Hospice Provider report category in the CASPER (Certification and Survey Provider Enhanced Reports) Reporting application.

It displays provider-level data regarding Hospice Item Set (HIS) records submitted successfully to CMS. The report displays the following information: 

Provider identification information



Provider CMS certification number (CCN) and facility identification number (FAC ID)



Number of HIS records submitted



Number of HIS records submitted on time



Percentage of HIS records submitted on time

More information is at https://www.cms.gov/Medicare/ Quality-Initiatives-Patient-Assessment-Instruments/ Hospice-Quality-Reporting/Spotlight.html.

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Ransomware Fact Sheet Posted The U.S. Departments of Homeland Security, Justice and Health and Human Services have posted a fact sheet on ransomware, entitled “Ransomware, What It Is and What to Do About It.” It is at http://hcanys.org/wp-content/uploads/2016/07/ RansomwareHHSDOJDHSadvice.pdf.

Ransomware is a type of malware (malicious software) distinct from other malware; its defining characteristic is that it attempts to deny access to a user’s data, usually by encrypting the data with a key known only to the hacker who deployed the malware, until a ransom is paid.

After the user’s data is encrypted, the ransomware directs the user to pay the ransom to the hacker (usually in a cryptocurrency, such as Bitcoin) in order to receive a decryption key.

However, hackers may deploy ransomware that also destroys or exfiltrates (unauthorized transfer of information from an information system) data, or ransomware in conjunction with other malware that does so.

The fact sheet covers: how to protect your networks from ransomware; how to respond to ransomware; what to do if infected with ransomware; and other helpful tips.

HCA members should share this fact sheet with their compliance staff.

Another important “fact sheet” on Ransomware and HIPAA is at http:/ /www.hhs.gov/sites/default/files/ RansomwareFactSheet.pdf.

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

aging of the Medicaid population, and it increased usage of physician and clinical services and prescription drugs.

National Health Expenditure Projections: 2015-2025 The U.S. Centers for Medicare and Medicaid Services’ (CMS) Office of the Actuary has released national health expenditure projections for 2015-2025.

With Medicare and home health spending expected to continue to increase, we expect that there will be further proposals to reduce Medicare home health expenses and HCA will remain vigilant in opposing any effort that harms access to care or imposes hardship on the provider infrastructure.

The report, along with a Health Affairs article, is at https://www.cms.gov/ResearchStatistics-Data-and-Systems/StatisticsTrends-and-Reports/ NationalHealthExpendData/ NationalHealthAccountsProjected.html.

Publications 

“The Genworth 2016 Cost of Long Term Care Survey”

Some findings are: 



https://www.genworth.com/about-us/ industry-expertise/cost-of-care.html

For 2015-25, health spending is projected to grow at an average rate of 5.8 percent per year. This is 1.3 percent faster than Gross Domestic Product (GDP) per year over this period; as a result, the health share of GDP is expected to rise from 17.5 percent in 2014 to 20.1 percent by 2025.



“Accounting for Social Risk Factors in Medicare Payment Programs: Identifying Social Risk Factors,” by National Academies of Sciences, Engineering, and Medicine http://tinyurl.com/jyzuqh4

Medicare spending growth is projected to average 6.7 percent in 2017-19, compared to 5.2 percent in 2016, and 7.6 percent from 2020 to 2025. This 7.6 percent increase reflects the baby boomers’ continuing to age into Medicare, and existing Medicare beneficiaries increasing their use of hospital and physician services.



Medicare home health spending is expected to grow an average of 6.76 percent from 2015 to 2025.



Medicaid spending is expected to grow 5.6 percent from 2017 to 2019 – considerably slower than in 2014-15, but faster than in 2016 (5.3 percent) – and 6.1 percent from 2020 to 2025.

This 6.1 percent increase reflects the



“Leveraging the Social Determinants of Health: What Works,” by Blue Cross Blue Shield of Massachusetts Foundation http://bluecrossfoundation.org/sites/ default/files/download/publication/ Social_Equity_Report_Final.pdf



“Medicare Spending at the End of Life: A Snapshot of Beneficiaries Who Died in 2014 and the Cost of Their Care,” by the Kaiser Family Foundation http://files.kff.org/attachme nt/Data-Note-Medicare-Spending-at-theEnd-of-Life

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

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