Jan. 3, 2017 Edition of The Situation Report

ACA

OT

GLOBAL CAP

CFEEC

As Congress reconvenes this week, Republicans and Democrats strategize on future of the Affordable Care Act, with GOP pushing a repeal plan.

The state has finalized a rule which would make more “white-collar” workers eligible for OT by increasing the salary thresholds for OT exemptions.

The latest state Medicaid Global Cap report finds spending above projections, including for home care.

NYS extends the timeline for CFEEC evaluations to remain valid when patients seek CBLTC.

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Your Source for HOME CARE News, Policy and Advocacy

Vol. 2, Issue 1 | January 3, 2017

COMING UP Northeast Home Health Leadership Summit: “Extreme Makeover, Home Care Edition” Jan. 17-19, 2017 The Colonnade Hotel Boston State Advocacy Day and PAC Reception Feb. 6-7, 2017 Albany, NY Feb. 6 (5-6:30 p.m.): PAC reception at HCA’s offices.

Feb. 7: Legislative committee and conference leaders to meet with the HCA Board of Directors in the morning (8 a.m. to noon); afternoon appointments for members to meet with legislators representing your district (12:30 to 4 p.m.)

Critical Advocacy Continues as New Minimum Wage Takes Effect HCA submits initial comments on DOH survey Advocacy for funding of the state’s new minimum wage (MW) levels remains at peak priority, with the new levels effective as of December 31, and next critical milestones immediately awaiting health plans, providers and workers.

HCA worked right to the wire at the New Year engaging both its home care provider and MLTC members to assess their MW funding status and implementation needs, and strenuously advocating those needs to state Department of Health (DOH) officials.

See WAGE p. 2

February Advocacy Day, PAC Reception and Your Survey Responses Needed The legislative stakes in 2017 are high, as state elected leaders face a possible multi-billion-dollar budget shortfall, and as the home care industry confronts major new and ongoing challenges such as a new minimum wage increase, regulatory obstacles and programmatic support needs. To make these issues heard, we urge you to attend HCA’s Advocacy Day Program and PAC Reception on February 6 and 7 in Albany when we’ll be pressing for payment reforms and program support in 2017.

INSIDE Critical Advocacy Continues as New Minimum Wage Takes Effect....................1 Feb. Advocacy Day, PAC Reception and Your Survey Responses Needed............1 eMedNY 2017 Seminars and Webinars Posted................................................4 ACA in Crosshairs as Congress Reconvenes This Week.....................................6 Influenza Prevalent – Flu Mask Requirement in Effect.......................................7 DOH to Conduct North Country Emergency Preparedness Exercise..................7 State White Collar Overtime Exemption Levels Finalized.................................9 NGS to Resume Round 2 of Probe-and-Educate Medical Reviews...................10 Watch This … and Come to Boston for Home Health Summit...........................11

See ADVOCACY p. 5 Managed Care Integrity Report Due in January................................................11 DOH Global Cap Report: Spending $25M over Projections for April to Sept. 2016...12 CMS Releases National Average Hospice Quality Data....................................13 Informational Bulletin Posted on Personal Care Services...............................14 FAQs Issued on HCBS Beneficiaries who Exhibit Unsafe Wandering Behavior....14 OSHA Issues Final Rule on Recordkeeping Requirements................................15 Change Made in CFEEC Evaluation...................................................................15 Medicaid Levels for 2017 Posted....................................................................16 CMS Reschedules Next Open Door Forum until Feb. 8........................................16 Ordering/Prescribing/Referring Providers Must Revalidate............................17 Resources.................................................................................17

The Situation Report: the Home Care Association of New York State

Volume 2, No. 1 January 3, 2017 

WAGE from p. 1 HCA pressed (and will continue to do so) for direct state assistance to MLTCs and providers encountering implementation difficulties, as well as across-the-board advocacy for the state’s delivery of promised MLTC, provider and worker funding, including manageable and fair guidance for all.

Throughout, HCA has also continued to underscore to DOH its statutory obligation – beyond its earmarked rate bump provided in the state budget – to provide actuarially sound and adequate funding levels for MLTCs and providers to comply with the new labor law, and all other laws and requirements applicable to quality patient care. (This statutory language – obligating the state to adequately fund plans and providers to enable them to meet the cost of state and federal statutes, and quality care – was enacted in this year’s state budget and on the basis of proposals from HCA.) Officials in multiple DOH bureaus handling MW implementation sought to be responsive to the flurry of outstanding issues that HCA relayed on behalf of providers and MLTCs. While DOH assisted to an extent – for which we are appreciative – the actions ultimately needed to create a stable, workable and confident course for support of the new MW law are yet a DOH work-in-progress.

One of these progressive steps is to better identify actual provider/plan/worker funding needs, particularly for budget appropriations for the 2017-18 state fiscal year at hand. Over the past week, DOH shared with HCA and other associations a draft survey it will soon send to home care providers to determine the financial impact of the minimum wage increases throughout the state and to assist in “developing a reimbursement methodology that will respond to the benchmarks for minimum wage salaries through the year 2021.”

The survey asks for the number of employed and contracted staff full time equivalents at various hourly wage bands and the numbers of hours they worked for a calendar year, and the percentage of wages spent on certain fringe benefits. DOH provided only a December 30 window for comments; HCA provided preliminary feedback based on our review and collaborative discussion with association colleagues, and requested DOH to consider comments from further provider vetting this week, which we have put into motion. Among our Home Care Association of New York State (HCA) 388 Broadway, 4th Floor, Albany, NY 12207 Tele: 518-426-8764; Fax: 518-426-8788; Website www.hcanys.org

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The Situation Report is a weekly publication of the Home Care Association of New York State (HCA). Unless otherwise noted, all articles appearing in The Situation Report are the property of the Home Care Association of New York State. Reuse of any content within this newsletter requires permission from HCA. Joanne Cunningham HCA President jcunningham@hcanys.org Roger L. Noyes Director of Communications, Editor of The Situation Report rnoyes@hcanys.org Al Cardillo Executive V ice President, Policy & Programs acardillo@hcanys.org Patrick Conole Vice President, Finance & Management pconole@hcanys.org Andrew Koski Vice President, Program, Policy & Services akoski@hcanys.org Alexandra Fitz 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 & Special Projects jkerbein@hcanys.org Billi Wilson Manager, Meetings & Events bwilson@hcanys.org Teresa Brown Administrative Assistant tbrown@hcanys.org

Volume 2, No. 1 January 3, 2017

The Situation Report: the Home Care Association of New York State preliminary feedback, HCA requested: clarifications on scope (e.g., whether the survey is intended to include managed care, fee-for-service and/or consumer directed personal assistance cases); use of the most current wage data set (2016 if possible); clarification as to whether CHHAs that contract out for all aide services need to complete the survey; clarity on DOH survey questions related to wage factors/variability for direct care, travel time, overtime, paid time off, etc.; and other issues. We stressed the need to verify with providers that the draft survey’s requested tabulations of wage bands are able to be captured, and represent meaningful data profiles.

As mentioned in the December 19 edition of The Situation Report, DOH will soon hold a Stakeholder’s Workgroup meeting to discuss further implementation and compliance requirements, including a streamlined cost report for home care providers and a plan attestation form.



See the tables below and on page 4 for the implementation timeline of the new wage requirements.

As the new year progresses, HCA will remain vigilant in its advocacy on this issue and overall payment adequacy needs of plans and providers.

HCA has already presented statutory and budgetary proposals to the Governor’s Office, Division of Budget, and key State Legislative Offices addressing plan/provider fiscal needs and will be further gearing up priority advocacy. Please see the related p. 1 story about our State Advocacy Day program on February 6 and 7. In addition to this program, we will be asking members to join us in many other grassroots outreach actions, so please be on the lookout for further information.

For more information, contact the HCA Policy staff.

Minimum Wage Increase New York City (11 or more employees; different amounts for those with fewer employees) Effective Date December 31, 2016 December 31, 2017 December 31, 2018

Minimum Wage Amount $11 per hour $13 per hour $15 per hour

Nassau, Suffolk and Westchester Effective Date

Minimum Wage Amount

December 31, 2016

$10 per hour

December 31, 2017 December 31, 2018 December 31, 2019 December 31, 2020

$11 per hour $12 per hour $13 per hour $14 per hour

December 31, 2021

$15 per hour

Rest of New York State Effective Date

Minimum Wage Amount

December 31, 2016 December 31, 2017

$9.70 per hour $10.40 per hour

December 31, 2018

$11.10 per hour

December 31, 2019

$11.80 per hour

December 31, 2020

$12.50 per hour*

*Any future increases up to $15 per hour will depend on actions by the state Division of Budget Director and the state Labor Commissioner based on certain economic indicators.

Minimum wage amounts are also on the NYS Department of Labor’s website at http://www.labor.ny.gov/workerprotection/laborstandards/workprot/minwage.shtm

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The Situation Report: the Home Care Association of New York State

Volume 2, No. 1 January 3, 2017 

State Wage Parity Law County

March 1, 2016 to December 31, 2016

December 31, 2016 to December 31, 2017

New York City

$10 + $1.69 additional wages and $2.40 supplemental benefit rate ($14.09 total)

$11 + $1.69 additional wages and $2.40 supplemental benefit rate ($15.09 total)

Nassau

$10 + $3.22 supplemental benefit rate ($13.22 total)

$10 + $3.22 supplemental benefit rate ($13.22 total)

Suffolk

$10 + $3.22 supplemental benefit rate ($13.22 total)

$10 + $3.22 supplemental benefit rate ($13.22 total)

Westchester

$10 + $3.22 supplemental benefit rate ($13.22 total)

$10 + $3.22 supplemental benefit rate ($13.22 total)

The state Home Care Worker Wage Parity levels are at http://www.health.ny.gov/health_care/medicaid/redesign/mrt_61.htm

NYC and County Living Wage Laws Region

Living Wage Levels

New York City

$10 per hour with health insurance benefits or $11.50 per hour without benefits (since 2006)

Nassau

$13.73 per hour with health insurance benefits or $15.78 per hour without benefits (August 1, 2016 to July 31, 2017)

Suffolk

$12.03 per hour with health insurance benefits or $13.69 per hour without benefits (2017)

Westchester

$11.50 per hour with health insurance benefits or $13 per hour without benefits (since 2006)

eMedNY 2017 Seminars and Webinars Posted The eMedNY Training Schedule (seminars and webinars) for January through March is now available.

Some of the topics offered include: 

ePACES for Dental, DME, Institutional, Professional (Real-Time), Physicians, Private Duty Nursing, and Transportation



Medicaid Eligibility Verification System (MEVS)



eMedNY Website Review



New Provider/New Biller

The schedule is at https://www.emedny.org/training/index.aspx.

Questions can be directed to the eMedNY Call Center at 800-343-9000.

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Volume 2, No. 1 January 3, 2017 

ADVOCACY from p. 1

To this end, right now we also need you to complete our Home Care Industry Survey, which seeks your responses on the payment and program issues facing your organization. The survey, which will be used in support of our advocacy goals, was previously shared with the membership. Please see our alert (at http://conta.cc/2gLAFGO) for a link and additional information. This critical survey should be completed by all HCA provider members. The due date is January 6: this coming Friday.

Advocacy Day: February 6-7 Our Advocacy Day program begins the evening of February 6, when HCA is holding a Political Action Committee (PAC) reception at our offices from 5 to 6:30 p.m., followed by a full day of meetings with state officials and legislators on February 7.

For this second day (February 7), we’ve invited key legislative committee and conference leaders to meet with the HCA Board of Directors in the morning (from 8 a.m. to noon). All HCA member leaders are invited to participate in this key opportunity for engagement with legislative and administrative decision-makers.

The February 7 Board meeting is followed by appointments, which you should schedule in advance, to meet with legislators representing your district. If you are an HCA Board Member, we are scheduling afternoon meetings for you and will notify you of the itinerary. All other agency leaders are invited to schedule appointments directly with your lawmakers (between 12:30 and 4 p.m. on February 7) to meet with your representatives in Albany. Please contact HCA in advance if you need assistance.

We’ll be providing all HCA members with advocacy documents ahead of time to inform your meetings.

The full two-day schedule is outlined in our flyer at http://hca-nys.org/wp-content/uploads/ 2016/12/2017-HCA-Advocacy-Day-Flyer.pdf.

Please take the time now to complete HCA’s Home Care Industry Survey, if you haven’t already, and download the flyer to register for our Advocacy Day Program and PAC Reception. This is an important opportunity for you to help us deliver a message in Albany about the need for home care support.

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Volume 2, No. 1 January 3, 2017 

ACA in Crosshairs as Congress Reconvenes This Week A new Congress is convening this week for the start of its 2017 session following a bellwether election season; and, now, efforts are already underway to repeal the Affordable Care Act (ACA).

As the House and Senate return to Washington today, the GOP enjoys majorities in both chambers, along with the impending inauguration of Republican President-elect Donald Trump on January 20. Republican leaders in both houses, as well as President-elect Trump, have vowed to make ACA’s repeal a priority, and both sides of the political divide – Democrats and Republicans – have immediately begun gearing up for conference discussions on their respective strategies.

Democrats are meeting with President Obama tomorrow to plan a strategy to protect ACA, the President’s signature health care law, while Republicans are expected to meet with Vice President-elect Mike Pence on an ACA-repeal plan.

Republican legislators have advanced ACA-repeal measures several times in the past. But now – with Republicans controlling both houses of Congress, as well an incoming Republican Presidency – an ACA repeal has gained significantly greater momentum. Nevertheless, it still remains unclear how and when a formal repeal action would take shape.

ACA’s individual insurance coverage mandate has long been at the heart of GOP repeal measures in the past, and it is possible that a Republican plan would maintain some other components of ACA, such as a requirement for insurers to cover pre-existing conditions and a measure that allows for children to stay on their parents’ health care plans until age 26. Democrats have vowed to oppose any substantive dismantling of the law, citing the approximately 20 million Americans who have gained insurance coverage through it.

While the ACA repeal-and-replace momentum is strong, this process is expected to take several months of negotiations. Budgetary maneuvers offer perhaps the biggest point of leverage for GOP leaders: that is, using a defunding strategy or other fiscal instruments to chip away at the taxation and subsidy components of ACA. Meanwhile, as HCA has reported in previous editions of The Situation Report, other major health care changes are likely to gain headwinds in the new political environment.

GOP leaders have reinvigorated proposals to turn Medicaid into a block-grant system. This means that Medicaid would no longer function as an open entitlement; instead, states would receive a defined, lumpsum grant from the federal government to administer their programs, rather than the federal government matching what the state pays for Medicaid. House Republican Leader Paul Ryan has also since recapitulated the GOP’s call for a premium-supported system under Medicare and the possibility of increasing the Medicare eligibility age threshold, among other key provisions.

But for now, the focus appears squarely on ACA. Continued on next page

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Continued from previous page This current political environment creates both risks and opportunities for home care. One component of ACA – the Medicare Face-to-Face (F2F) requirement – continues to be a target of HCA advocacy, though it is unclear how, or whether, a F2F repeal would be on the agenda for any of the Congressional actions underway.

Nevertheless, HCA will be pushing for mitigation of this disastrous mandate, either through legislation or executive action.

HCA has eyed several other regulatory requirements for action in the new Congress and will be working with our federal legislative affairs representative, Brett Heimov of Envision Strategy, to brief the new Congress and pave a plan for action on these priorities in the coming weeks.

Influenza Declared Prevalent – Flu Mask Requirement in Effect On December 28, the state Department of Health (DOH) Commissioner declared influenza to be prevalent in New York State.

This means that home care and other health care workers who are not vaccinated against influenza for the current influenza season must wear surgical or procedure masks in areas where patients are typically present.

The announcement is at http://www.health.ny.gov/press/releases/2016/2016-12-28_influenza_prevalent.htm.

Amendments to the “flu mask” regulations – which went into effect during the 2013-14 influenza season – allow for the removal of masks when health care workers are accompanying patients in the community, providing speech therapy services, or communicating with persons who lip read.

Frequently asked questions about this requirement and other resources are at http://health.ny.gov/ FluMaskReg. Additional information about influenza, including how it is monitored in New York State, is at http:// www.health.ny.gov/diseases/communicable/influenza/seasonal/.

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

DOH to Conduct North Country Regional Emergency Preparedness “Extreme Weather” Exercise State Department of Health (DOH) officials have discussed with HCA plans to conduct an “extreme weather” emergency preparedness exercise this month for providers serving counties in the North Country area of the state.

The Capital District Health Emergency Preparedness Coalition (HEPC) North Country Sub Regional Extreme Weather Work Group is conducting this exercise on January 12 for providers approved to serve North Country

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Volume 2, No. 1 January 3, 2017 

counties including Clinton, Essex, Franklin and Hamilton counties. The exercise will simulate the approach and impact of a significant ice storm.

Home care agencies are asked to participate in this important exercise, along with hospitals, county health departments and emergency medical services. Home care is being specifically included to identify vulnerable patients who may be impacted in the region.

In preparation for the approach of a significant ice storm, the Health Emergency Response Data System (HERDS) survey will be activated the day before the exercise on January 11, 2017. You may receive a phone call from your county health department to discuss patients potentially impacted by the storm during the exercise.

Agency participation will be voluntary, but all agencies serving the exercise region are urged to participate.

DOH will send notification via IHANS (Integrated Health Alerting and Notification System) alert to all CHHAs, LTHHCPs, LHCSAs and Hospices that are approved to serve patients in Clinton, Essex, Franklin and Hamilton counties.

A HERDS survey activity entitled “North Country Extreme Weather Exercise Home Care” will be activated on the Health Commerce System. If your agency currently provides services to patients in any of the counties as listed above, you will be asked to complete and submit the HCEMRAGENCY-Home Care Emergency Agency Form and the HCEMRCAPACITY-Home Care Emergency Response Capacity Form for this drill.

The survey activity will be open from 8 a.m. to 2 p.m. ONLY on January 11, 2017.

Data will be collected one time only for this drill and all data must be submitted by 2 p.m. Agencies must use actual patient demographic information and should report on all patients in order to determine the number of patients potentially impacted by an ice storm.

In the last week of October and first week of November, a similar exercise was conducted for providers in the western region of the state, and home care was likewise a participant. HCA also participated with DOH and regional HEPC officials in the planning of home care’s role for that event.

Home care’s participation is invaluable on a number of levels, and DOH has previously allowed agency participation to qualify in fulfillment of an agency’s annual exercise protocol.

HCA will be participating in the debriefing/after-action review of the exercise and will share any information, insights and recommendations.

For further information, please contact Nancy Simonds at DOH at HCEmergency@health.ny.gov; or HCA’s Alex Blais at ablais@hcanys.org or Al Cardillo at acardillo@hcanys.org

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New State White Collar Overtime Exemption Levels Finalized On December 28, the state Department of Labor (DOL) posted a rule that finalizes originally proposed increases in the income thresholds for employers to classify their employees as exempt from overtime pay (“white collar exemption”).

The notice is at https://docs.dos.ny.gov/info/register/2016/dec28/pdf/rulemaking.pdf (page 29); the first increase is effective December 31, 2016.

The state’s original proposed regulations are at https://labor.ny.gov/legal/laws/pdf/minimum-wage/19amended-rule.pdf.

Currently, the salary threshold for classification as an exempt executive or administrative employee under New York State law is $675 a week. This is well below the updated Fair Labor Standards Act (FLSA) “whitecollar” exemption salary threshold of $913 per week that was set to take effect December 1, 2016 under federal regulations, but has been “stayed” due to a November 22, 2016 Decision and Order of the District Court for the Eastern District of Texas. (See the November 22 edition of The Situation Report.) The state levels are in effect despite the federal court ruling. If the court ultimately rules in the federal government’s favor, then providers would then be required to comply with the federal levels as well.

The final state rule increases the overtime exemption income threshold for “executive” and “administrative” staff as shown in the chart below.

Employer type and location

Effective dates and weekly salary threshold amounts

Dec. 31, 2016

Dec. 31, 2018

Dec. 31, 2019

Dec. 31, 2020

Dec. 31, 2021

NYC (11 or more employees)

$825

$975

$1,125

Ͳ

Ͳ

Ͳ

NYC (10 or fewer employees)

$787.50

$900

$1,012.50

$1,125

Ͳ

Ͳ

$750

$825

$900

$975

$1,050

$1,125

$727.50

$780

$832

$885

$937.50

Ͳ

Nassau, Suffolk, & Westchester Counties Remainder of State

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Dec. 31, 2017

The Situation Report: the Home Care Association of New York State

Volume 2, No. 1 January 3, 2017 

NGS to Resume Round 2 of Probe-and-Educate Medical Reviews The U.S Centers for Medicare and Medicaid Services (CMS) has instructed Medicare Administrative Contractors (MACs), including National Government Services (NGS) covering New York, to begin Round 2 of the medical review and reporting under the Home Health “Probe-and-Educate” medical review audit.

These review audits relate to claims submitted by home health agencies (HHAs) for Medicare home health services and patient eligibility (certification/re-certification), including the face-to-face (F2F) requirement, as outlined in CMS’s 2015 home health final rule (1611-F).

For round 2, MACs are expected to have begun sending Additional Documentation Requests (ADRs) on or after December 15, 2016. This round of claim reviews and provider education will conclude in approximately one year.

Similar to Round 1, CMS is again directing MACs to sample five claims for pre-payment review from each HHA within their jurisdictions, excluding those providers who had five claims reviewed in Round 1 that resulted in zero or only one claim in error. MACs will continue to focus on compliance with CMS-1611-F, as well as to make sure all other coverage and payment requirements are met.

Based on the results of these reviews, MACs will conduct provider-specific educational outreach. CMS will instruct MACs to deny each non-compliant claim and to outline the reasons for denial in a letter to the HHA, which will be sent at the conclusion of the probe review portion of the process. CMS will also instruct the MACs to offer individualized phone calls/education to all providers with errors in their claim sample. During such calls, the MAC will discuss the reasons for denials, provide pertinent education and reference materials, and answer questions.

For those providers that are identified as having moderate or major concerns (two to five denials out of five), the MACs will repeat the probe-and-educate process for dates of services occurring after education has been provided as part of Round 2.

Additional information is explained in Medlearn Matters article SE1524 at: https://www.cms.gov/Outreachand-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1524.pdf.

Given major concerns with the F2F requirement, and this particular probe-and-educate initiative, HCA has been at the forefront of efforts to seek repeal of the F2F requirement, or, barring repeal, changes to the rule that would be significantly less arduous and ease the duplicative and costly documentation mandate for home care agencies and other practitioners.

We’ve repeatedly engaged New York’s Congressional Delegation, which issued an HCA-prompted letter to CMS sharing our recommendations to change the F2F rule. Those recommendations would allow for the requirement to be documented on the existing plan-of-care, as opposed to a separate, duplicative and onerous process which CMS continues to insist upon. HCA is redoubling these efforts as Congress reconvenes, with the Senate and House considering a series of health care legislative measures during a changing political leadership environment in Washington.

For further information, contact Patrick Conole at (518) 810-0661 or pconole@hcanys.org.

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Watch This … and Come to Boston on January 17-19 for Northeast Home Health Leadership Summit The 2017 Northeast Home Health Leadership Summit in Boston is just a month away! Check out our new video on YouTube (https://youtu.be/jaIcQa47aJo) to see what’s in store for you and other home health leaders from throughout the northeast.

If you haven’t yet registered, please do so now, and join your colleagues from eight states convening for learning and collaboration! This Summit is the biggest, most important home care conference coming to the region early in 2017, offering a once-a-year opportunity to network with colleagues from neighboring states.

Nearly a dozen expert speakers will be on hand to discuss: the Washington policy landscape; post-acutecare opportunities; bundling initiatives and value-based payments; care management strategies; home care labor laws; leadership tools; and much more.

Everything you need to know is on the conference website at www.nehomehealthsummit.com.

Managed Care Integrity Report Due in January All Managed Care Organizations subject to the requirements of the March 1, 2014 Medicaid Managed Care/ Family Health Plus/HIV Special Needs Plan Model Contract are reminded that the 2016 Annual Program Integrity Report must be submitted to the state Office of the Medicaid Inspector General (OMIG) between January 1, 2017 and January 31, 2017.

The Report will only be accepted electronically and must be submitted securely.

The March 1, 2014 Model Contract at section 18.5( a)( xix) states: The Contractor (Managed Care Organizations) shall conduct an annual assessment and submit to OMIG an annual report, in a form and format to be determined by the state Department of Health (DOH) and OMIG, of the status of their conformity with all contractor regulatory and contractual

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Medicaid program integrity obligations (list to be developed by DOH and OMIG) by December 31 of each calendar year.

On February 2, 2016, OMIG announced the publication of the report form and list of program integrity obligations.

The Managed Care Annual Program Integrity Report form, reporting and submission instructions, as well as additional guidance and information, are available at the links below.

•

MCO Annual Program Integrity Report Form: https://omig.ny.gov/images/stories/mco-comprehensiveprovider-report/MCO_Annual_Program_Integrity_Report_20151021.docx

•

Reporting and Submission Instructions: https://omig.ny.gov/resources/reporting-and-submissioninstructions-managed-care-organization-annual-program-integrity-report

•

Additional Guidance: https://www.omig.ny.gov/images/stories/mco-comprehensive-provider-report/ MCO_Annual_Program_Integrity_Report-Extension_Announcement.pdf

Questions regarding the Managed Care Annual Program Integrity Report may be directed to mcopireport@omig.ny.gov.

DOH Global Cap Report: Spending $25M over Projections for April to Sept. 2016 The state Department of Health (DOH) has recently issued a detailed six-month Medicaid Global Cap report.

This latest report covers the first half of the 2016-17 state fiscal year (FY) (April 1, 2016 through September 30, 2016).

The full report is at: https://www.health.ny.gov/health_care/medicaid/regulations/global_cap/monthly/ sfy_2016-2017/docs/apr-sept_2016_report.pdf.

The Medicaid Global Cap for the overall current fiscal year (April 1, 2016 to March 31, 2017) is $18.6 billion for all sectors, representing a 5.1 percent increase (or $814 million) from the previous FY. The annual growth in the Global Cap of $814 million over last year includes costs associated with both price and enrollment increases, offset by a net change in one-time revenue and spending actions, as well as the continuation of Medicaid Redesign Team (MRT) initiatives.

DOH’s report finds that overall spending for the first half of the 2016-17 FY was $25 million above the Medicaid Global Cap projection, across all sectors.

Among the pressures on spending for this period is the Fair Labor Standards Act (FLSA) rule change requiring overtime paid at time and one-half of actual wages (versus minimum wage), with travel time as compensable hours, and changes to live-in rules for home care. However, DOH confirmed in a 2016 meeting with HCA and other association representatives that the Medicaid Global Cap projections will not include any

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additional Medicaid spending due to the phase in of the $15-per hour statewide minimum wage, as these expenses will be kept outside the cap.

According to the March Global Cap report, the category that includes home care (“Other Long Term Care”) was $26 million over projected spending. The Department shows actual spending of $319 million versus projected spending of $293 million for the first half of FY 2016-17. DOH attributes this change to higher than expected utilization through September. There were 2,230 more individuals receiving personal care services than anticipated. Medicaid Managed Care (MMC) was $41 million over projections, a difference of $7.376 billion (actual spending) versus $7.335 billion (estimated spending).

Total Medicaid enrollment reached 6,088,949 enrollees at the end of September 2016. This reflects a decrease of 78,341 (1.3 percent) since March 2016. The decrease is attributed to 39,020 individuals that were previously counted as Medicaid members converting to the Essential Plan, and a decreased enrollment of 39,321 individuals. The number of Medicaid enrollees in the managed care program has increased by 7,499 since March 2016, and decreased in FFS programs by 85,840.

Through the end of September, the state’s Accounts Receivable (A/R) balance was $220 million, reflecting a net recovery of $105 million since March 2016. The state expected to recoup $194 million of the balance by the end of FY 2017-18.

A/R recoupment plan As previously reported by HCA, DOH is currently engaged in an initiative to eliminate all outstanding retroactive Medicaid liabilities owed to the state by March 31, 2017. As a result, DOH will adjust all retroactive rate liabilities processed on August 1, 2015 and forward that cannot be fully paid within 12 months. This adjustment will apply a recoupment rate higher than the standard 15 percent to ensure that liabilities are paid within 12 months from the date of the first recoupment.

HCA is surveying these global cap reports carefully in an information gathering effort, combined with other data analysis, to ensure accurate reflections of home care finances, with an eye toward any indication of rate or payment decisions stemming from the state’s analysis of home care’s performance.

For further information, contact Patrick Conole at (518) 810-0661 or pconole@hcanys.org.

CMS Releases National Average Hospice Quality Data The U.S. Centers for Medicare and Medicaid Services (CMS) recently released national averages of the quality of care measure scores of Medicare-certified hospices on its website at https://data.medicare.gov/ .

National average data are available for the following two quality-of-care datasets: 1. The Hospice Item Set (HIS); and Continued on next page

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Continued from previous page 2. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey.

The HIS information reflects provider performance on the seven National Quality Forum (NQF)-endorsed HIS measures from Quarter 3 of 2015 through Quarter 2 of 2016 (July 2015 through June 2016).

The CAHPS Hospice Survey information contains the national average “top-box” scores of Medicarecertified hospices on the eight NQF-endorsed CAHPS Hospice Survey measures. Top-box scores reflect the proportion of respondents who gave the most favorable response or responses for each measure. Scores are calculated from CAHPS Hospice Survey responses that reflect care experiences of informal caregivers (i.e., family members or friends) of patients who died while receiving hospice care in Quarter 2 of 2015 through Quarter 1 of 2016 (April 2015 through March 2016).

For further information, contact Patrick Conole at (518) 810-0661 or pconole@hcanys.org.

Informational Bulletin Posted on Personal Care Services On December 13, 2016, the U.S. Centers for Medicare and Medicaid Services (CMS) released an information bulletin to the states and other stakeholders regarding personal care services (PCS). The bulletin describes PCS, summarizes the program integrity vulnerabilities, and highlights safeguards state Medicaid agencies can put in place to strengthen program integrity in PCS without undermining beneficiary access to PCS, especially self-directed services.

The bulletin is at https://www.medicaid.gov/federal-policy-guidance/downloads/cib121316.pdf.

Specifically, the bulletin includes information on: assuring program integrity and beneficiary autonomy in self-directed PCS; establishing provider qualifications and training requirements; registries of PCS attendants; screening of PCS providers; verification of the need for services; documentation of claims; prepayment edits; post-payment review and audits.

FAQs Issued on Medicaid Beneficiaries in HCBS who Exhibit Unsafe Wandering Behavior The U.S. Centers for Medicare and Medicaid Services (CMS) has issued Frequently Asked Questions (FAQs) with guidance on how to comply with its home and community-based setting (HCBS) rule for individuals with dementia or other conditions in which unsafe wandering or exit-seeking behavior is exhibited.

The FAQs are at https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/FAQ121516.pdf.

The HCBS setting rule is at https://www.gpo.gov/fdsys/pkg/FR-2014-01-16/pdf/2014-00487.pdf.

States are required to comply with the rule following a transition period that ends March 17, 2019.

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Continued from previous page As explained in many prior communications, the HCBS federal rule establishes criteria for what is considered a home and community setting under many Medicaid waiver programs, including managed long term care and mainstream Medicaid managed care.

The rule identifies settings or services that present institutional qualities and, therefore, do not meet the requirements necessary for Medicaid-funded home and community-based settings. These settings include those: located in a publicly or privately owned facility that provides inpatient treatment; are on the grounds of, or immediately adjacent to, a public institution; or that have the effect of isolating individuals receiving Medicaid-funded HCBS from the rest of the community.

New York State’s website on the federal rule is at http://health.ny.gov/health_care/medicaid/redesign/home_community_based_settings.htm.

OSHA Issues Final Rule on Recordkeeping Requirements The Occupational Safety and Health Administration (OSHA) has issued a final rule that amends its recordkeeping regulations. The amendments clarify that the duty to make and maintain accurate records of work-related injuries and illnesses is an ongoing obligation. The duty to record an injury or illness continues for as long as the employer must keep records of the recordable injury or illness; the duty does not expire just because the employer fails to create the necessary records when first required to do so.

The final rule is at https://www.gpo.gov/fdsys/pkg/FR-2016-12-19/pdf/2016-30410.pdf.

According to OSHA, the amendments add no new compliance obligations and do not require employers to make records of any injuries or illnesses for which records are not currently required to be made.

The amendments were made in response to a decision of the U.S. Court of Appeals for the District of Columbia Circuit, in which a majority held that the Occupational Safety and Health Act does not permit OSHA to impose a continuing recordkeeping obligation on employers.

Currently, employers, including home health and hospice, are required to record information about certain injuries and illnesses occurring in their workplaces, and to make that information available to employees, OSHA, and the Bureau of Labor Statistics.

OHSA materials on recordkeeping requirements are at https://www.osha.gov/recordkeeping/index.html.

Change Made in CFEEC Evaluation In late December, the state Department of Health (DOH) posted guidance to inform MLTC plans of an extension – from 60 to 75 days – in the amount of time a consumer’s Conflict Free Evaluation and Enrollment Center (CFEEC) evaluation for community based long term care (CBLTC) services remains valid.

The guidance is at http://www.health.ny.gov/health_care/medicaid/redesign/mrt90/mltc_policy/docs/1608.pdf.

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Continued from previous page When DOH implemented CFEEC, it incorporated the requirement that any individual voluntarily seeking CBLTC services could not be enrolled into an MLTC plan until the CFEEC conducted an evaluation determining CBLTC eligibility. At that time, a consumer’s CFEEC evaluation was only valid for sixty days.

Effective immediately, the CFEEC evaluation for CBLTC eligibility is valid for 75 days. After such time, a new evaluation will be required if the consumer does not select an MLTC plan but continues to seek CBLTC. This change only applies to the expiration of the consumer’s CFEEC evaluation and in no way impacts the MLTC plan’s assessment period.

Any questions regarding this information can be directed to CF.Evaluation.Center@health.ny.gov.

Medicaid Levels for 2017 Posted The state Department of Health (DOH) has posted the 2017 Medicaid levels.

The guidance is at http://www.health.ny.gov/health_care/medicaid/publications/pub2016gis.htm (GIS 16 MA/18).

The income and resource levels for individuals and couples are the same as in 2016. They are: 

$825 income per month and $14,850 resources for individuals.



$1,209 income per month and $21,750 resources for couples.

Some changes include: 

The maximum monthly maintenance needs allowance is $3,022.50 (up from $2,980.50 in 2016).



The maximum community spouse resource allowance is the greater of $74,820 or the amount of the spousal share up to $120,900 ($119,220 in 2016).



The amount of equity interest an individual can have in a home and still be eligible for Medicaid coverage is $840,000 (up from $828,000).

CMS Reschedules Home Health, Hospice & DME Open Door Forum to Feb. 8 The next Home Health, Hospice and DME Open Door Forum has been rescheduled from January 11, 2017 to February 8, 2017, from 2 to 3 p.m.

CMS will provide additional information regarding the agenda and call-in information in the near future and HCA will update the membership with that information.

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Ordering/Prescribing/Referring Providers Must Revalidate for Claims to be Paid The state Department of Health (DOH) reminds home care and other providers that they are at risk for not being paid when ordering/prescribing/referring (OPR) providers have not complied with revalidating their enrollment.

Federal regulation requires state Medicaid agencies to revalidate the enrollment of all providers every five years. For many providers, Medicaid payment is contingent on the OPR provider also revalidating its enrollment in Medicaid.

OPR providers who do not comply with the revalidation requirement will be terminated from the Medicaid program.

Because this has the potential to result in significant non-payable claims, DOH urges agencies to reach out and encourage their OPR providers to revalidate their enrollment.

Agencies should confirm that their OPR provider is enrolled before rendering service by visiting: www.emedny.org/info/opra.aspx.

The Claim Adjustment Reason Code for non-enrolled OPR providers on your remittance will be as follows: “B7 – This Provider was Not Certified/Eligible to be Paid For this Procedure/Service on this Date of Service.”

The required revalidation form and instructions are available at https://www.emedny.org/info/ ProviderEnrollment/index.aspx. The completed form must be mailed, with all required documentation and fee (if required), to the address provided on page 2 of the form.

Questions should be addressed to the eMedNY Call Center at 800-343-9000, Option 2.

Resources 

“What Are the Implications of Repealing the Affordable Care Act for Medicare Spending and Beneficiaries?” by the Kaiser Family Foundation http://files.kff.org/attachment/Issue-Brief-What-Are-the-Implications-of-Repealing-the-AffordableCare-Act-for-Medicare-Spending-and-Beneficiaries



“Continuation of the Home Health Probe and Educate Medical Review Strategy,” by the U.S. Centers for Medicare and Medicaid Services http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/SE1635.pdf



“Medicaid Personal Care Services: CMS Could Do More to Harmonize Requirements across Programs,” by the Government Accountability Office http://www.gao.gov/assets/690/681213.pdf

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

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