ASAP
A Weekly Publication Of HCA Home Care Association of New York State
Legislative Issues Public Policy
News
Volume 21, No. 28 July 29, 2016
Calling All Women Health Leaders: Join HCA for a C-Suite of Offerings at First-ever Women in Healthcare Leadership Summit Top-tier, nationally recognized women thought-leaders, communications experts, researchers, authors and popular-media voices will share their wisdom and skills as part of HCA’s inaugural Women in Healthcare Leadership Summit on September 28 and 29 in Saratoga Springs. The conference offers a “C-Suite” of universal skills and insights to empower women executives in all healthcare subsectors: business and finance; lobbying; government policymaking; strategy consulting; law; and other areas where women leaders aspire to enhance their talents, skills and leadership potential within healthcare. See WOMEN p. 2
HCA Submits Comments on Concerning Medicare Home Health Pre-Claim Review Demonstration Last week, HCA submitted comments on the Medicare Home Health Pre-Claim Review Demonstration being initiated by the U.S. Centers for Medicare and Medicaid Services (CMS). Though this Demonstration does not currently apply to New York State, HCA was compelled to
DOH Posts Anticipated FLSA Survey Due back August 26 Late yesterday, the state Department of Health (DOH) posted a long-anticipated survey to measure the costs faced by home care providers due to the recent Labor Standards Act (FLSA) changes. These changes include: paying overtime at time-and-a half of the aide’s regular rate of pay instead of time-and-a half of minimum wage, paying aides for travel time, new costs for some 24-hour live-in cases, and others. See SURVEY p.7
See DEMO p. 5 Inside ASAP HCA Offers First-ever Leadership Summit for Women.....................1 HCA Comments on Pre-Claim Review Demo....................................1 DOH Posts Anticipated FLSA Survey..................................................1 Concerned about Workers’ Compensation Costs?..........................6 Additional FLSA Funding Available Soon......................................7 LTHHCP: Q&A to Clarify Operation, Roles, Opportunities..............8 DOH Announces DSRIP Updates........................................................9 OMIG Posts New Compliance Alert...................................................9 HCA Posts 2015 MLTC & PACE MMCOR Data.............................10 HCA Gives Feedback on OMIG’s Private Duty Audit Protocols.....10 RFA Now Open For Health Transformation Funds........................11 DOH Seeks Input on FIDA.................................................................12 Kaltenbach Now COO of MZL Home Care Agency..........................13 Kate Rolf Appointed to National Rural Health Committee.............14 CMS Provides Medicare Hospice Payment Update.........................15 New Labor Task Force Targets Home Care......................................16 CMS Proposes New Bundled Payment Models...............................17 Additional DOH Staff Changes.........................................................19 MedPAC Releases 2016 Data Book.................................................19 NGS Updates.................................................................................19 Publications..................................................................................20
Reminder Reminder: HCA is on a biweekly summer ASAP schedule. Our next edition will be published on August 12. We will keep you posted by e-mail about any breaking updates.
Helping New Yorkers Feel Right At Home
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WOMEN from p. 1
international dialogue about women’s health, sexuality and power. She’ll offer insights about the timeless and essential ingredients to leadership growth, success and collectively cracking the glass ceiling in the healthcare industry and beyond.
To download a brochure, register, learn more about the summit, or become a sponsor, please visit http://hca-nys.org/ general-news/hcas-first-ever-women-in-healthcare-leadershipsummit-sept-28-29-in-saratoga. “New York State has some of the most prominent women leaders in healthcare, but the reality is that women are vastly underrepresented in executive-level healthcare positions here and throughout the United States,” said HCA President Joanne Cunningham. “This summit addresses an unmet need for skill-development, networking and self-empowerment.”
“Research strongly suggests that a higher representation of women on corporate boards and on leadership teams helps enhance an organization’s overall performance, which is critical in a healthcare business and policy environment that rewards outcomes first and foremost,” Ms. Cunningham added. “When women gain the tools to achieve their personal career goals, not only do they benefit, but so do the organizations they lead.” Among the speakers at the September 28-29 Summit are:
Nancy Miriam Hawley, founder of the Boston Women’s Health Book Collective, Inc., which was responsible for writing the best-seller Our Bodies, Ourselves, a classic text that shifted the national and
Karen Friedman, an international communications expert, former television news anchor, writer, and author of the best-selling book Shut Up and Say Something (Praeger Publishing). Her expertise drew the attention of former Secretary of State (and Presidential candidate) Hillary Rodham Clinton who chose Ms. Friedman to provide media and political training for women in South and Central America. She’ll offer the same sort of training at the Leadership Summit, showing women leaders how to best tap their unique perspectives as women to
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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communicate with maximum impact across diverse audiences.
Bethany Gilboard, CEO of Innovative Health Alliance of New York and Alliance for Better Healthcare, LLC, a successful veteran of health care industry strategy and one of the state’s most prominent women healthcare leaders, who will share her unique perspective on tackling tough professional and personal challenges and dilemmas.
Vicky Hines, a home care leader and previous HCA Board Chair, who has risen through the ranks to become Chief Operating Officer of the University of Rochester Medical Faculty Group. As a leading policy voice in healthcare, Ms. Hines will offer tips for professional development that can lead to the best career choices.
Dr. Jacqueline Hornor Plumez, author of The Bitch in Your Head: How to Finally Squash Your Inner Critic, who will present tools and techniques to combat negative thinking – a perspective that has led to her appearances on The Today Show and Good Morning America, as well as articles in Ladies’ Home Journal and The New York Times Magazine.
Rachel Soares of the Catalyst Research Center for Equity in Business Leadership, who directs research to identify the global gender leadership gap, investigate myths that restrain women’s advancement into corporate leadership, and explore how diversity, leadership and performance intersect. Her session will acquaint attendees with the principles of “sponsorship,” offering concrete strategies to get sponsored and be a sponsor.
The program will also include a women’s mini-expo of vendors, networking receptions, and a chance for women to obtain a free executive headshot for their C.V. or professional networking platforms. Please join us for this first-of-a-kind conference to cultivate your c-suite spirit! 3
HCA ence is HCA’’s next BIG confer conference our Senior and Financial Manager’ eat at the Manager’ss Retr Retreat Mohonk Mountain Resort in New Paltz on September 8 to 9. Have you registered yet? This program delves into all of the major home care finance issues you need to learn about, including: rate updates; big-picture items, like new models of care; the mechanics of such issues as employee wage, hour and overtime policies as well as home care reimbursement changes; and new areas of exploration. Download the brochure and register today on our education page at http://hca-nys.org/eventseducation/upcoming-events.
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DEMO from p. 1 provide feedback, as this Demonstration may be applied to New York or nationally in the future and it presents very significant concerns. The Medicare Home Health Pre-Claim Review Demonstration was initially a Prior Authorization Demonstration, but was changed after strenuous objections by HCA, other provider associations and over 100 members of Congress. HCA also previously submitted comments on the initial Prior Authorization program. The Demonstration is being initiated in five states identified by CMS as “high risk”: Massachusetts, Illinois, Florida, Texas, and Michigan. Under the Pre-claim Review Demonstration, home health agencies (HHAs) in these states must submit: A request for pre-claim review to the Medicare Administrative Contractor (MAC) for each episode of care; Documentation from the medical record that supports medical necessity and demonstrates that the Medicare home health coverage requirements are met (including the face-to-face/F2F encounter); A request for pre-claim review at any time before the final claim is submitted. The review process must occur before the final claim is submitted for payment. The MAC is expected to send the HHA a decision affirming or non-affirming the pre-claim review request within targeted timeframes of 10 business days of the first request and 20 business days of resubmitted requests. During one of the CMS Open Door Forums held on this program, HCA raised concerns about the requirement that HHAs must obtain signed physician orders – as opposed to verbal orders – for initiating the pre-claim review process. This was supported by other Open Door participants. While CMS said it would reexamine this requirement, the policy has not changed. In our comments, HCA explains that the current documentation requirements will lead to long delays in HHAs initiating the process and obtaining a determination on its pre-claim review request. This documentation includes signed physician orders, F2F encounter evidence and other articles which all must be submitted as part of the pre-claim review process. We describe the numerous problems encountered by HHAs in obtaining signed orders and documentation to meet the F2F rule. “CMS should conclude from [its Probe and Educate] reviews and other home care claims experience that there is a major issue with the requirements for documenting home health eligibility, as opposed to an indication of fraud and abuse in home health,” we state in our comments. “Also, there seems to be little consistency among the MAC staff and we fear that this will carry over into the pre-claim review demonstration.” HCA adds: “The expectations put on doctors regarding their written records to show that their patients are eligible for Medicare-covered home health are unreasonable, unrealistic and overwhelming. Until CMS simplifies the documentation requirements, we expect that the pre-claim review demonstration will result in many ‘non-affirmed’ requests.” Furthermore, requiring that all this documentation be submitted with the request for a pre-claim review “will delay agencies in requesting a pre-claim review decision and leave the agency in limbo as to whether 5
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their final claim will be approved. Secondly, requiring agencies to utilize this process for every 60-day episode of care will create an unreimbursed and tremendous paperwork burden on agencies. We expect that HHA staff will have to spend countless hours in obtaining and submitting documents multiple times to the MACs as the HHAs are told that their pre-claim review was not affirmed and they are told to send additional evidence.” In addition, our comments point out that CMS already has many existing tools and auditing entities at its disposal to address Medicare integrity issues, including but not limited to: Recovery Audit Contractors (RACs) Zone Program Integrity Contractors (ZPICs) State-level surveillance agents (targeting Conditions of Participation adherence) Third-party liability payment auditors Office of the Inspector General MACs’ “Probe and Educate” reviews HCA also stressed that the pre-claim review process will increase costs to Medicare, home health providers, MACs and worsen an already massive backlog of appeals. We mention that HHAs are already “subject to devastating rebasing reductions and other reimbursement cuts that already underpay these existing cost obligations, not to mention the new cost obligations of a pre-claim review process, which has a direct impact on the initiation of services,” and we urge CMS to rescind this proposed Demonstration and solicit feedback from the provider community on more appropriate ways to address Medicare integrity issues. Given that documentation is the key area of alleged noncompliance, we request that CMS instead opt for education, clear guidelines and compliance standards, and provider support in place of the pre-claim review proposal. Our comments can be viewed in their entirety in the “Letters and Comments” section of our website: http://hca-nys.org/ category/letters-and-comments. CMS has posted several informational materials on preclaim review, including a revised Frequently Asked Questions document, an Operational Guide, and an overview. They are at https://www.cms.gov/Research-Statistics-Data-andSystems/Monitoring-Programs/Medicare-FFSCompliance-Programs/Pre-Claim-Review-Initiatives/ Overview.html. 6
Is Your Agency Interested in Reducing Workers’ Compensation Costs? Please reserve your seat today at the next session in our Home Care Survival Bootcamp Education Series: Addressing Factors that Increase Workers’ Compensation Costs and Developing Ways that Home Care Providers Can Reduce Their Expenses. This session will be held on September 28 from 9:30 a.m. to noon in New York City. The financial burden of Workers’ Compensation has been increasing for home care providers due to numerous factors. Agencies face the potential for additional increases due to the recently enacted $15 minimum wage and a shrinking Workers’ Compensation insurance market. By developing a cohesive Workers’ Compensation riskmanagement strategy, home care agencies can play an active role in reducing their costs. Learn from an insurance industry expert with the firm Marshall & Sterling, Inc. about pricing issues and the need to understand how insurance companies and their agents decide these issues. When it comes to Workers’ Compensation, in particular, the goal is to help employers understand what the insurance underwriters are doing, why they’re doing it, and how they’re doing it, so that your agency can leverage that information to positively impact your bottom line. To register, please download the brochure at http://hca-nys.org/wpcontent/uploads/2016/06/Sept-28Survival-Bootcamp-Work-CompCosts-and-Expense-Reduction.pdf.
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SURVEY from p. 1 The DOH survey was developed and modified with input from HCA and the other provider associations in order to help the state to ascertain the actual costs faced by agencies under the FLSA changes. As stated in the survey, DOH “intends to utilize this information to form the basis for the determination of appropriate program change adjustments to fee schedules and/or capitation rates.” The information requested in the survey is in reference to the time periods of 2014, and between October 2015 and March 2016. It requests responses, by region, about the:
Number of hours of aide services provided Number of overtime hours Average hourly rate paid to aides Number of Medicaid home care clients Number of 24-hour live-in cases Travel expenses Other costs
Throughout the process of survey development, HCA advocated for a brief survey that captured only important FLSA-related information and minimized sections related to travel expenses. A quick review of the survey shows that it is very detailed and will take more time to complete than anticipated. DOH has provided some funding to help home care providers with the FLSA changes under Medicaid fee-forservice and managed care. However, those funds for managed care patients only cover the period of October 13, 2015 to March 31, 2016, and DOH has said that any new funding will be up to negotiation between providers and health plans. (See sidebar story on this page.) The survey is due August 26 and must be submitted online. It can be accessed at http://www.health.ny.gov/health_care/ medicaid/redesign/fair_labor_standards_act.htm (under FLSA Updates). HCA and the other provider associations have identified a number of concerns with the survey rollout. These include: a short timeframe to send questions (August 5); giving the associations as the first place to contact; and DOH’s decision not to hold a webinar to help agencies with the survey (as we jointly suggested). We intend to further raise these issues with DOH. All questions about the survey must be sent by August 5 to NY.FLSA@mercer.com. DOH intends to post a Frequently Asked Questions document by August 12. 7
Additional FLSA Funding Available Soon The state Department of Health (DOH) has announced that the federal-share of funding to assist home care providers in complying with the final Fair Labor Standards Act (FLSA) rule change, for the period of October 13, 2015 to March 31, 2016, will be paid to the MLTC plans via checks dated August 10. Plans will then have 30 days to pass the funds to their home care contractors. DOH previously advised HCA that a federal-share of $22.8 million (the same amount given to the plans earlier as the state-share of the FLSA monies) will be available in this August 10 payment, and that plans are expected to pass-through the federal monies to their home care providers in the same amounts as they did with the state-share. These funds are intended to help home care providers with new costs faced under the FLSA final rule, including paying overtime at timeand-a half of the aide’s regular rate of pay instead of time-and-a half of minimum wage; travel expenses; costs of 24-hour sleep-in cases; and others. HCA has repeatedly raised concerns to DOH about the distribution of these funds, including: the documentation required of providers; differences in methods used to determine the amounts that home care providers should receive; the varied amounts that providers have received from plans; the lack of any mechanism to appeal the
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amounts; and the untimely flow of funds. Despite vigorous HCA objection, DOH has indicated that it will not be providing additional funds to meet the FLSA requirements after March 31, 2016 and any new funding will be up to negotiation between providers and health plans.(Please see related p. 7 story about additional FLSA funding.) HCA continues to work with DOH and other provider associations to assure that the problematic distribution of FLSA funding is not repeated in monies appropriated to assist home care providers with the upcoming minimum wage increases. We will also continue to press our agenda for payment adequacy of all labor and mandate costs, as reflected in legislation that HCA advanced earlier this year, which we are priming for consideration in state budget negotiations or other legislative vehicles.
LTHHCP: Q&A to Clarify Operation, Roles, Opportunities A draft questions-and-answers (Q&A) document for the LTHHCP is in progress and reportedly under “active review” at the state Department of Health (DOH). This new Q&A is intended to assist LTHHCPs, MLTCs, local social services districts, performing provider systems (PPSs) and other stakeholders with guidance on LTHHCP status, operation and roles in the restructured Medicaid and health system. The Q&A would clarify the standing of LTHHCPs, their operating authority and service roles under state and federal statutes, and certain procedures in the new service delivery structure. This guidance would help respond to questions (and much misunderstanding and confusion) in the wake of ongoing state reforms, especially several new LTHHCP developments such as: 1) the recent finalization of the Department’s statewide enrollment of LTHHCP Medicaid and dual eligible Medicaid-Medicare recipients into managed care; and 2) the final extension/expiration of the specific 1915(c) federal waiver for non-state plan Medicaid services offered by the LTHHCP (per GIS 16 MA/11). Much confusion has surrounded the LTHHCP’s provider standing and capability ever since the Medicaid Redesign Team (MRT) implemented broad system reforms in 2011 and 2012, in particular mandatory managed care enrollment and the consolidation of waivers and programs under the state’s comprehensive 1115 federal waiver. Many LTHHCP providers have continued providing services both directly and under various contractual arrangements around the state. However, with patients transitioned to managed care and little guidance on the LTHHCP’s status under these reforms, providers have faced declining patient censuses, along with the perception of a potentially dwindling program service roles and future opportunity area. The anticipated Q&A would aim to clarify and affirm to LTHHCPs and all stakeholders the LTHHCP’s standing and capability. It could also potentially reveal new opportunity areas and help clear up the misunderstanding about LTHHCP’s utility and operation. Even in the wake of MRT reforms, LTHHCPs have been virtually all designated by DOH as “safety-net” providers for the Delivery System Reform Incentive Payment (DSRIP) program. LTHHCPs, as dual Medicare and Medicaid certified providers, can well position themselves under Value Based Payments. 8
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Thus, the Q&As would inform critical LTHHCP decisions about strategic partnerships, future resources and structures.
OMIG Posts New Compliance Alert
HCA has been reaching out to DOH to expedite the Q&As and provide other support for LTHHCPs. Upon finalization, HCA will ask DOH to convene a webinar – or join one sponsored by HCA – to review the Q&As and identify any additional questions or needed guidance.
The state Office of the Medicaid Inspector General (OMIG) has posted a new Compliance Alert (2016-01), which provides notice of the August 1, 2016 increase in the Civil Monetary Penalties by the U.S. Department of Justice.
DOH Announces DSRIP Updates This week, the state Department of Health (DOH) announced some updates regarding the Delivery System Reform Incentive Payment (DSRIP) Program. These are summarized below. Round 3 regulatory waiver requests due August 1 Once again, Performing Provider System (PPS) leads have been invited by the state Department of Health (DOH), Office of Mental Health (OMH), Office of Alcoholism and Substance Abuse Services (OASAS), and the Office for People With Developmental Disabilities (OPWDD) to submit additional Regulatory Waiver requests to DOH by August 1, 2016. Responses to these requests will be sent to the PPS leads by October 1, 2016 and posted on the DSRIP website. In September 2014, these government agencies issued guidance on the submission of these requests. That guidance is available here: https://www.health.ny.gov/health_care/medicaid/ redesign/dsrip/regulatory_flexibility_guidance.htm. Further information, including past waiver requests, the regulatory waiver request template, as well as deadlines and response dates can be viewed here: https://www.health.ny.gov/ health_care/medicaid/redesign/dsrip/ reg_flex_guide_res_prog_stat_waiver_resp_approvals.htm. Integrated services webinar The Integrated Services webinar, held on July 14, 2016, has been posted to the DSRIP website in the “Integrated Services” section of the “Webinar and Presentations” webpage at https:// www.health.ny.gov/health_care/medicaid/redesign/dsrip/ webinars_presentations.htm. Continued on next page 9
The Alert can be viewed at: http://on.ny.gov/ 2a5MqIZ. Under the Deficit Reduction Act (DRA) of 2005, the penalties apply to Medicaid providers that receive or make annual payments under the state Medicaid plan of at least $5 million. Further information about the DRA requirements may be found in OMIG’s Compliance Library at https:// www.omig.ny.gov/ compliance/compliancelibrary. Effective August 1, 2016, the False Claims Act civil penalty increases to a range of $10,781 to $21,563 per claim and the Administrative Remedies civil penalty will change to $10,781 per claim.
ASAP – a publication of the Home Care Association of New York State Continued from previous page Updated DSRIP FAQs Revised FAQs have been posted to the DSRIP website at: https:// www.health.ny.gov/health_care/medicaid/redesign/dsrip/dsrip_faq/ index.htm. Question no. 2 in the PPS section of the DSRIP Frequently Asked Questions (FAQ) was revised to mitigate confusion caused by the original answer. The item is revised as follows: Q: Can a provider still join a PPS at this point in time? If yes, can you still participate in the financial incentive payment? (Revised July 2016) A: At this time, the PPS provider networks are closed. However, annually PPS networks will reopen for the addition of new partners for performance purposes only. We recommend reaching out to the PPS in your region regarding participation. A list of PPS contact information can be found on the DSRIP website at: http://www.health.ny.gov/health_care/medicaid/ redesign/dsrip/providers_professionals.htm. The answer was revised to eliminate the following sentence, which had caused confusion: “At DSRIP midpoint, providers may be added for valuation.” Please refer to the revised wording for informational purposes.
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HCA Provides Feedback on OMIG Audit Protocols for Private Duty Nursing This week, HCA submitted comments to the state Office of the Medicaid Inspector General (OMIG) on its draft audit protocols for private duty nursing services provided by LHCSAs. In our comments, we request OMIG to revise three protocols which are incorrect or require clarification. These include: 1. Timeframe for obtaining signed physician orders;
Any questions may be directed to dsrip@health.ny.gov.
2. PPD skin test requirement; and
Members-Only HCA Data Webpage Now Includes 2015 MLTC & PACE MMCOR Data
3. Criminal history checks for nurses.
This week, we posted to our members-only “HCA Data” webpage an HCA-developed spreadsheet of the 2015 fourth quarter Medicaid Managed Care Operating Reports (MMCORs) for each MLTC and Program of All-Inclusive Care for the Elderly (PACE) plan in the state. Important: HCA Data is a members-only page that provides data reports to assist home care and hospice providers and managed care plans in their benchmarking efforts, understanding of system-wide trends, and access to reimbursement and premium rates. The page is not visible on our site unless you are logged in with an HCA member website account. Our log-in page is here: http://hca-nys.org/login. Upon login, the HCA Data link will appear in the site menu at the top right. You can 10
HCA has provided feedback to OMIG on numerous audit protocols and appreciates that it has reached out to us on private duty nursing protocols. HCA will be holding its annual Corporate Compliance program on October 6 in Albany; more information on this signature program will follow soon.
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also enter your e-mail address to obtain your password. Or, simply e-mail HCA’s Communications Director Roger Noyes at rnoyes@hcanys.org if you do not yet have an HCA website account. HCA’s 2015 MMCOR spreadsheet summarizes key MMCOR data, including such items as:
Plan enrollments Per-member-per-month premium revenue and premium income or loss Unit costs Personal care and home health aide utilization and other information
Last month, HCA posted the 2014 Medicaid Cost Reports for all non-hospital based CHHAs and LTHHCPs in the state to this page as well. HCA Data is just one of many resources for members and is only visible if you log-in to our website. Please use HCA’s website to find information and updates. Once logged-in, you will see a blog feed on our home page offering virtually every important member resource or update, including recent e-mail alerts, policy memos, archives of our ASAP newsletter and more. For further information, contact Patrick Conole at (518) 810-0661 or pconole@hcanys.org.
Grant RFA Now Open For State Health Transformation Funds Includes HCA-sought dedicated pool for home and community based providers; learn more at August 8 applicant webinar The state Department of Health (DOH) has released a Request for Applications (RFA) under the Statewide Health Care Facility Transformation Program, which includes HCA-sought dedicated funding for home and community-based providers. The RFA can be accessed on DOH’s website (http://www.health.ny.gov/funding/rfa/1607010255/ index.htm) or through the Grants Gateway website here (https://grantsgateway.ny.gov/ intelligrants_NYSGG/module/nysgg/goportal.aspx?NavItem1=4&ngoID=5000607). Applications must be submitted in the Grants Gateway by 4 p.m. on Friday, September 16, 2016. HCA and community health provider representatives worked in partnership to push for this transformation funding during budget negotiations, convincing the Legislature and Governor to dedicate a portion of these funds for home and community-based providers specifically. At our urging, the final initiative includes a minimum of $30 million dedicated for the home and communitybased sector as part of the entire $195 million pool otherwise available for all sectors. While the $30 million minimum is dedicated to home and community-based providers, specifically, these entities are also eligible for funding in the remainder of the pool as well. The goal of this program is to provide grants that primarily support capital projects (but it may include noncapital expenses such as debt restructuring) “for the purpose of strengthening and protecting continued access to health care services in communities throughout New York State and associated with a merger, 11
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consolidation or significant corporate restructuring activity that is part of an overall transformation plan intended to create a financially sustainable system of care.” Non-capital projects, in addition to debt restructuring, that may be eligible for funding include general operating expenses directly connected to the eligible project for which funding is sought as well as non-capital expenses in cases where the RFA does not explicitly mention them as excluded. Those excluded are general operating expenses applicable to day-to-day operations and unconnected to the eligible project for which funding is being sought. The overall pool is open to health care providers fulfilling a health care need for acute inpatient, outpatient, primary, home care or residential health care services in a community. Home and community-based providers, eligible for at least $30 million of this total amount, are defined as diagnostic and treatment centers, mental health and alcohol and substance abuse treatment clinics, primary care providers and home care providers. A letter of intent is due August 19, though DOH indicates this is optional. DOH has also announced an Applicant Webinar on Monday, August 8 at 1 p.m. Participants must register in advance at https:// meetny.webex.com/meetny/onstage/g.php?MTID=e31794d9a38496235b755383458cb4e0c. Potential applicants may continue to submit questions related to the RFA at healthcarefacilitytransformation@health.ny.gov until Wednesday, August 10. Responses to all questions will be posted to the DOH website on or about August 17, and made available to all webinar participants.
DOH Seeks Input on FIDA On July 22, the state Department of Health (DOH) provided an update on the Fully Integrated Duals Advantage (FIDA) program and sought input on the future of FIDA. The webinar provided updated FIDA statistics, discussed recent reforms, and outlined an upcoming advertising campaign and outreach mailings. Some of the prominent data includes:
FIDA enrollment totals 5,370 including 1,620 in Brooklyn; 1,153 in the Bronx; 1,118 in Queens; 982 in Manhattan; 345 in Nassau; and 152 in Staten Island. This is much less than the state originally estimated and the state has been looking for ways to encourage enrollment. As a comparison, over 150,000 individuals statewide are enrolled in MLTC partial capitation plans.
The five largest plans are VNSNY, HealthFirst, GuildNet, Fidelis and Elderplan.
The largest number of those who have opted out of FIDA reside in Brooklyn (48 percent), Queens (20 percent), Manhattan (16 percent), Bronx (10 percent), Nassau (4 percent) and Staten Island (2 percent).
Zip codes with the highest opt outs tend to have a large number of FIDA eligibles who speak Russian, Chinese and Spanish and a large number of FIDA eligibles who are currently enrolled in a Medicare Advantage managed care plan.
The number of monthly disenrollments has decreased from 747 in January to 184 in June. Continued on next page 12
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Continued from previous page
65 appeals have been filed since June 2015, including almost half (30) related to personal care services.
Some of the recent reforms include: fewer assessments for enrollees transferring from an existing MLTC or FIDA plan, more flexibility in the Interdisciplinary Team (IDT) process, less rigid marketing rules, among others. DOH will conduct a four-month multifaceted advertising campaign and outreach mailings. Mailings will target: 1) Medicare providers who have provided services to FIDA eligibles between January and July 2016 (about 9,000); 2) consumers who have opted out of FIDA and are still FIDA eligible; and 3) consumers who have joined MLTC since December 2014 and never opted out of the FIDA program. DOH discussed the future of FIDA and is seeking comments on whether to extend the program into Suffolk and Westchester in 2017 or 2018 and whether to request federal approval for a two-year extension of FIDA for the period from January 1, 2018 to December 31, 2019. The July 22 handouts are at https://www.health.ny.gov/health_care/medicaid/redesign/2016/docs/ 2016-07-22_stakeholder_update.pdf.
Home Care Leader Walter Kaltenbach Appointed COO of MZL Home Care Agency Walter Kaltenbach – a longtime executive in home care and member of HCA – was recently appointed Chief Operating Officer of Brooklyn-based MZL Home Care Agency, which joined as an HCA provider member earlier this year. Mr. Kaltenbach has over 20 years of leadership experience in home health care services, including at Premier Health Care, People Care, and Able Health Care, where he served as CEO for sixteen years before coming to MZL. He has been a dedicated political advocate at both the state and federal levels, lending his voice particularly on behalf of special-needs individuals through programs served under the Office for People With Developmental Disabilities (OPWDD) system. Kaltenbach Mr. Kaltenbach has a record of successfully negotiating and acquiring strong referral source contracts with managed care organizations, implementing companywide performance improvement plans, mentoring senior executive staff, and increasing revenue. He has been an active and engaged member of HCA’s Policy Council for several years, providing insight and expertise on emerging issues facing home care policy, and was appointed to the HCA Board of Directors in 2015. MZL Home Care Agency is part of the Gefen Senior Care group, providing home and community based services since 1998. MZL is the LHCSA component of this group, delivering home care services under 13
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contract to CHHAs, hospices and MLTCs in the five boroughs of New York City, Long Island and Westchester Rockland, Dutchess and Putnam counties, while operating offices in Brooklyn, Queens and Long Island. MZL provides a wide variety of home care services including home health aides, personal care aides, housekeeping, and chore services. MZL also provides skilled care services such as assessments, including through the Uniform Assessment System (UAS-NY). HCA congratulates Mr. Kaltenbach on the recent appointment, appreciates MZL for joining HCA as members, and looks forward to Mr. Kaltenbach’s ongoing leadership voice in the HCA community and Board as we continue to tap his insights on advocacy, policy, program development, reimbursement, and regulatory and operational issues.
Recent Board Member Kate Rolf Appointed to National Advisory Committee on Rural Health and Human Services HCA Member Kate Rolf, President and Chief Executive Officer of Syracuse-based VNA Homecare, has been appointed to a four-year term on the National Advisory Committee on Rural Health and Human Services (NACRHHS) of the Health Resources and Services Administration. NACRHHS is comprised of 21 nationally recognized rural health experts who advise the Secretary of the U.S. Department of Health and Human Services on ways to address health care issues across rural America. “I am excited to have this opportunity to contribute to such an important body,” Ms. Rolf said. “The potential to influence federal policy as it relates to rural America is an honor, especially given that approximately 1.5 million New Yorkers live in areas designated as rural by the United States Department of Agriculture.” Ms. Rolf brings a wide range of health policy expertise to the committee. She has more than 20 years of leadership experience and is an active member of several community organizations. She has served on Rolf the HCA Board of Directors, where Ms. Rolf recently completed her term as Board Treasurer, and received HCA’s 2015 prestigious Advocacy Award. Ms. Rolf currently serves on the Board of Directors for the Visiting Nurse Associations of America (VNAA) and LeadingAge New York, where she chairs the Home and Community Based Service Cabinet. HCA has long focused on the needs of home care providers in rural areas. On the reimbursement front, we’ve successfully advocated for the continuation of the rural add-on for Medicare home health services. We have also worked closely with the New York State Legislative Commission on Rural Resources to press a series of legislative initiatives that support the rural delivery of home care, but those measures are applicable to all home care service regions. Our initiatives include home care access to discretionary grant funding and regulatory flexibility. HCA applauds the Health Resources and Services Administration for appointing Ms. Rolf to the NACRHHS, where she will be a strong New York home care voice on behalf of rural health delivery issues.
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CMS Provides Medicare Hospice Payment Update The U.S. Centers for Medicare and Medicaid Services (CMS) has identified three issues that are affecting payments for the two-tier routine home care (RHC) payment and the service intensity add-on (SIA) payment. The following is a summary of each issue and the timeframe for when those issues might be corrected. Two-Tier RHC Payments Issue: The two-tier payment rate is not being applied appropriately to claims submitted on or after January 1, 2016. In some instances, the Medicare system is incorrectly paying at a low rate, instead of the high rate, causing an underpayment to providers. In other instances the Medicare system is incorrectly paying the RHC at a high rate, when the low rate is appropriate. The Medicare system is checking a single prior benefit period and not all benefit periods that are not separated by 60 days. This inappropriate payment is causing an overpayment to providers. C MS will be providing instructions to the Medicare Administrative Contractors (MACs) in the January 2017 release to correct the Medicare system issue. Providers currently do not need to take action and should not report any overpayments on their credit balance reports. SIA Payment Issue: In certain situations, the Medicare system is not applying the end-of-life (EOL) SIA payment to the previous month’s claim, when a patient dies within the first few days of a month. The Medicare system is designed to trigger an automatic adjustment of the prior month’s claim if the prior month’s claim is eligible for the SIA payment. This adjustment will apply the EOL SIA amounts to the previous claim that could not be identified in the initial processing. These adjustments are not occurring on the prior month’s claim in the following situations:
When the incoming claim does not contain a qualifying RHC service;
When the provider adjusts the original claim to add qualifying (or additional) RN and/or MSW visits; and
When the provider adjusts the IUR (32G) claim that originally applied the SIA payment, and the adjustment claim removes all EOL SIA payments.
CMS plans to issue instructions to the MACs in the January 2017 release to correct the Medicare system issue. Providers currently do not need to take action and should not submit an adjustment claim for the previous month, nor does the provider need to submit an appeal. This is a Medicare system issue; CMS will update providers on claims adjustments when additional information becomes available. For further information, contact Patrick Conole at (518) 810-0661 or pconole@hcanys.org.
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Task Force on Employee Exploitation and Misclassification Established; Home Care Targeted Last week, Governor Cuomo signed Executive Order No. 159 to establish a Permanent Task Force on Employee Exploitation and Misclassification. The new task force represents a merger of the Exploited Worker Task Force, the Nail Salon Industry Enforcement Task Force and the Joint Enforcement Task Force on Employee Misclassification. According to the Governor’s press release (http://www.governor.ny.gov/news/governor-cuomoannounces-employers-repay-nearly-4-million-back-wages-and-damages-more-7500), the new executive order will expand its focus to examine a variety of ways in which workers are exploited such as unpaid wages, unpaid overtime, health and safety violations, and other instances of worker exploitation. The effort spans 15 target industries, including home health care. According to the Governor’s press release, the new Task Force will “bring together unemployment insurance investigators, wage investigators and workers compensation investigators with the investigators and personnel of task force agencies to comprehensively scrutinize employers engaged in the underground economy.” The Governor also announced that the Task Force to Combat Worker Exploitation has directed 1,547 businesses to pay nearly $4 million in back wages and damages to more than 7,500 workers since its inception in July 2015. This is included in the Task Force’s 2016 report at https://www.governor.ny.gov/ sites/governor.ny.gov/files/atoms/files/EWTFReport_Final.pdf. This Task Force conducted more than 120 investigations in industries that included home health care. According to the report, the Task Force (and presumably the new Permanent Task Force on Employee Exploitation and Misclassification) will explore enhancing enforcement of wage standards in the home health care industry and take actions in other areas. Efforts may include amending contracts to require evidence of compliance with wage parity laws, engaging employers to communicate consequences of noncompliance, auditing employers, and enhancing penalties. The report notes that the Task Force held hearings across the state and at two of these sessions home health care workers spoke of issues such as the failure to receive minimum wage and overtime, required off-theclock work, and meal period violations. Additionally, they cited shift issues, including unpredictable and long work hours coupled with lack of meal breaks. The labor laws and regulations that affect home care workers are complex, varied and confusing. Home care agencies are surveyed and audited by a multitude of entities and may face the added scrutiny of the Governor’s newly announced Task Force. Home care providers are advised to consult with trained professionals in labor law and ensure that they are in compliance with the relevant rules. The executive order is available at http://www.governor.ny.gov/news/no-159-establishing-permanentjoint-task-force-fight-worker-exploitation-and-employee.
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CMS Proposes New Bundled Payment Models New Opportunity for Home Health Providers The U.S. Centers for Medicare and Medicaid Services (CMS) has proposed new bundled payment models for hospitals that work with home care and other post-acute care providers.
processes to coordinate care, CMS has proposed a number of measures to ease the transition, including gradually phasing-in risk. The program is scheduled to run for five years, from 2017 to 2021. Downside risk (possible repayments to Medicare) would be phased in:
These bundles include: new models for cardiac care; an extension of the existing model for hip replacements to include other hip surgeries; and a new model to increase cardiac rehabilitation utilization. Under the proposed episode payment models, the hospital in which a patient is admitted for care would be accountable for the cost and quality of care provided to Medicare fee-for-service beneficiaries during the inpatient stay and for 90 days after discharge. Participating hospitals would be paid a fixed target price for each care episode, and those that deliver higherquality care would get a higher target price. At the end of a model performance year, actual spending for the episode (total expenditures for related services under Medicare Parts A and B) would be compared to the target price that reflects episode quality for the responsible hospital. Hospitals that work with physicians and other providers to deliver the needed care for less than the quality-adjusted target price, while meeting or exceeding quality standards, would be paid the savings achieved. Hospitals with costs exceeding the quality-adjusted target price would be required to repay Medicare. Phased Implementation
July 2017 – March 2018 (performance year 1 and quarter 1 of performance year 2): No repayment; April 2018 – December 2018 (quarters 2 through 4 of performance year 2): Capped at 5 percent; 2019 (performance year 3): Capped at 10 percent; and 2020 – 2021 (performance years 4 and 5): Capped at 20 percent.
Gains (payments from Medicare to hospitals) would be phased in:
July 2017 – December 2018 (performance years 1 and 2): Capped at 5 percent; 2019 (performance year 3): Capped at 10 percent; and 2020 – 2021 (performance years 4 and 5): Capped at 20 percent.
The first performance period would run from July 1, 2017 to December 31, 2017. The second through fifth performance periods would align with calendar years 2018 through 2021. Targeted Areas For the new cardiac bundles, participants would be hospitals in 98 randomly-selected metropolitan statistical areas (MSAs). Hospitals outside of these geographic areas would not participate in the model. There is no application process.
Recognizing that hospitals will need time to adapt to the new models and establish 17
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Because some of the new hip surgery models, specifically hip/femur fracture surgeries, build upon the existing Comprehensive Care for Joint Replacement (CJR) model, CMS proposes to test these bundled payments in the same 67 MSAs that were selected for that model. These include the New York regions of Buffalo, New York City, Long Island and the northern metropolitan area. Collaboration with Other Providers According to CMS, one of the major goals of bundled payments is to encourage coordination among all providers involved in a patient’s care, including hospitals, physicians, home health providers and skilled nursing facilities. Therefore, as in the CJR model, CMS is proposing to allow hospital participants to enter into financial arrangements with these other providers as well as with Medicare Shared Savings Program Accountable Care Organizations (ACOs). Those arrangements would allow hospital participants to share reconciliation payments, internal cost savings, and responsibility for repayment to Medicare with other providers and entities that choose to enter into these arrangements, subject to the limitations outlined in the proposed rule. Thus, these new bundled payment models offer opportunities for home health agencies to collaborate with other providers to provide home care services. Cardiac Rehabilitation Incentive Payments One announced cardiac model will test the effects of payments that encourage the use of cardiac rehabilitation services. The cardiac rehabilitation incentive payment model will examine the impact of providing an incentive payment to hospitals where beneficiaries are hospitalized for a heart attack or bypass surgery, which would be based on beneficiary utilization of cardiac rehabilitation and intensive cardiac rehabilitation services in the 90-day care period following hospital discharge. Hospitals may use this incentive payment to coordinate cardiac rehabilitation and support beneficiary adherence to the cardiac rehabilitation treatment plan to improve cardiovascular fitness. These payments will be available to hospital participants in 45 geographic areas that were not selected for the cardiac care bundled payment models, as well as 45 geographic areas that were selected for the cardiac care bundled payment models. The proposed rule can be viewed at https://innovation.cms.gov/Files/x/advancing-care-coordinationnprm.pdf. For more information on the Cardiac Bundled Payment Models, go to https:// innovation.cms.gov/initiatives/epm/. Information on the Cardiac Rehabilitation Incentive Payment Model is available at: https:// innovation.cms.gov/initiatives/cardiac-rehabilitation/. For more information on the CJR Model, visit: https://innovation.cms.gov/initiatives/cjr.
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Additional DOH Staff Changes The state Department of Health (DOH) has announced the appointment of Margaret Willard as the Deputy Director of the Division of Home and Community Based Services, Office of Primary Care and Health Systems Management. Ms. Willard will be working with Rebecca Fuller Gray, Director of the Division of Home and Community Based Services. Ms. Willard brings extensive experience with her to this new role gained through her many years of working in the area of long term care service delivery. Most recently, as the Bureau Director in the Division of Long Term Care in the Office of Health Insurance Programs, she has played an integral role in implementing the transition of community based services into MLTC models. HCA has worked closely with Ms. Willard over many years and looks forward to continuing this close relationship in her new position. A series of earlier DOH staff changes were outlined in the July 15 ASAP, including the appointment of Andrew Segal, former Director of External Affairs and Government Relations at Visiting Nurse Service of New York, as Director of Long Term Care in the Office of Health Insurance Programs, and the appointment of Mark Kissinger as Special Assistant to the Commissioner for Long Term Care.
MedPAC Releases 2016 Data Book The Medicare Payment Advisory Commission (MedPAC) has released its 2016 data book on health care spending and the Medicare program. The report is available at http://medpac.gov/documents/data-book/june-2016-data-book-health-carespending-and-the-medicare-program.pdf?sfvrsn=0. Some topics include: Medicare beneficiary demographics; dual eligible beneficiaries; quality of care; postacute care; Medicare managed care; and other services.
NGS Updates National Government Services (NGS), New York’s Medicare Administrative Contractor (MAC), posted the following update to its website.
Using NGSConnex to Submit Documents in Response to an Additional Documentation Request – NGS will soon allow Part A providers to submit documents in response to an additional documentation request (ADR) in its self-service portal, NGSConnex. NGS will make this feature available beginning on July 30. Being able to electronically submit documentation for an ADR allows providers to respond directly through NGSConnex with no need to mail or fax one’s response to complete the process. Continued on next page 19
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Continued from previous page
NGS Provider Enrollment Revalidation Sessions – During the month of August, NGS will be hosting five “Let’s Chat about Provider Enrollment Revalidation” sessions. They will focus on provider enrollment revalidation information, validating one’s Medicare enrollment information via Internet-based PECOS, or completing the appropriate CMS-855 paper application. NGS staff will also review how to use the CMS Medicare Revalidation List search tool on the CMS website. The sessions will be held on August 3, 9, 18, 24, 30. Registration is at https://www.NGSMedicare.com. Select the Education tab, then “Webinars and Teleconference & Events.”
For further information, contact Patrick Conole at (518) 810-0661 or pconole@hcanys.org.
Publications
“Medicaid Coverage of Social Interventions: A Road Map for States,” by Manatt Health for the NYS Health Foundation http://nyshealthfoundation.org/uploads/resources/medicaid-coverage-of-social-interventions-issuebrief-july-2016.pdf
“Mis-Managed Care: Fair Hearing Decisions on Medicaid Home Care Reductions by Managed Long Term Care Plans, June – December 2015,” by Medicaid Matters New York http://medicaidmattersny.org/cms/wp-content/uploads/2016/07/Managed-Long-Term-Care-FairHearing-Monitoring-Project-2016-07-14-Final.pdf
“Report to Congress: Fraud Prevention System Third Implementation Year,” by the U.S. Centers for Medicare and Medicaid Services http://hca-nys.org/wp-content/uploads/2016/07/Fraud-Prevention-System-ThirdImplementation-Year1.pdf
For more information, contact Andrew Koski at (518) 810-0662 or akoski@hcanys.org.
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