06/29/2016

Important Updates from ODM for SNF Providers: Quality Payment; Rates; QIT Update; NF-LOC Changes

Important Updates from ODM for SNF Providers:
Quality Payment; Rates; QIT Update; NF-LOC Changes

SNF Quality Adjustment Payment

The Ohio Department of Medicaid (ODM) is still working to finalize the number of quality points earned by facilities and how some of the points will be distributed.  Terry Moore, Chief, Rate Setting conveyed that only three (3) centers in the state will not receive the quality point for the Preferences in Everyday Living Inventory (PELI).  Moore reported that ODM contacted all providers who did not mark the PELI box on their cost reports to confirm that they had in fact, not met the requirements, and all but three (3) corrected their reports.  In addition, all facilities are expected to receive the point for potentially preventable admissions as ODM does not have sufficient and “good” data to calculate this indicator in a consistent and uniform manner.  

Approximately 60% of SNFs will earn the point for staff retention, which will be based on 75% retention and not the 75th percentile as previously indicated by ODM.  Cheryl Guyman, Nursing Facility Policy Administrator noted that ODM is still attempting to determine how best to calculate the two (2) MDS-based measures, pressure ulcers and antipsychotics as several providers do not have a sufficient sample size to qualify.  ODM is considering alternatives to equitably address those providers whose score is blank due to sample size.  Due to the challenges with the data, it is likely that more providers will earn more points than previously projected.  This will impact (could decrease) the amount that each quality point will be worth because ODM based the projected calculation of $.82 per quality point from the data run by ODM in 2015 estimating the majority of facilities would earn an average of 2 quality points.

SNF Prices and PA1/PA2 Rate Change July 1, 2016
Terry Moore (ODM) provided an updated table (below) with the final prices to be used for July 1, 2016 rate setting.  The table includes peer group average case-mix scores to project average rates by peer group. The only change from LeadingAge Ohio’s previous Plante Moran update is amended cost reports for capital which resulted in a one cent decline in Peer Group 2-Large.   There have been no changes to facility-specific rates as shared individually by LeadingAge Ohio from the data received by ODM.

Peer Group	Direct Care Price	Direct Care Rate	Ancillary	Capital	Tax	Add-on	Quality W/hold	Quality Paid	Total Rate
1-L	40.84	105.03	58.99	11.11	2.38	16.44	(1.79)	1.79	193.95
1-S	40.84	105.03	61.65	10.50	2.04	16.44	(1.79)	1.79	195.66
2-L	38.91	102.65	61.15	10.17	2.16	16.44	(1.79)	1.79	192.57
2-S	38.91	102.65	63.85	10.79	1.96	16.44	(1.79)	1.79	195.69
3-L	36.03	94.70	57.68	7.99	1.43	16.44	(1.79)	1.79	178.24
3-S	36.03	94.70	56.84	9.54	1.43	16.44	(1.79)	1.79	178.95

*Note:  NF quality points yet to be finalized

Effective July 1, 2016, facilities with residents in the PA1 and PA2 RUG categories will receive a $115 flat rate.  July 1 also signifies the conversion to RUG IV which will result in more residents qualifying for the flat rate than previously.  Although, the statute calls for a lower rate of $91.70 for those facilities not cooperating with the state to relocate low-acuity patients, ODM officials confirmed that they do not plan to apply the lower rate unless an “extreme situation” is brought to their attention.  ODM has assured the associations that they will plan to discuss the application of a lower rate for a facility with the associations should a concern be brought to their attention.

Application of NF Patient Liability Under a Skilled Stay

Cheryl Guyman shared that the patient liability (PL) when calculated is always due even if a patient is on a skilled Part A stay.  The NF should bill the patient for the calculated patient liability and any unapplied PL should stay as a credit balance.  The PL cannot be applied to any unpaid patient days such as co-insurance. 

Ohio Benefits Conversion Implications
Effective August 1, 2016, the CRIS-E system for determining eligibility will be retired and Ohio Benefits will go live for the Aged, Blind and Disabled (ABD) populations.  Though there are various changes that still need to be determined, there are some key pieces that have been established.  This change will mean that the ABD population, similar to all other Medicaid populations, will be determined using the Modified Gross Adjusted Income criteria (MAGI) for baseline eligibility.  This will allow for nursing facilities to bill more quickly since baseline eligibility will be determined.  Thus, baseline eligibility will be applied to short-term NF Medicaid beneficiaries and the long-term care services asset test will only be applied once the individual has been determined to be long-term care.  Further changes will include the elimination of the 9401 and patient liability, coverage periods of eligibility; Restricted Medicaid Coverage Periods (RMCP) will be accessible through the MITS portal.  In addition, it is anticipated that in early fall, the NF-based level of care (LOC) process will be handled in the Hospital Exemption Notification Systems (HENS 2.0).  Facilities currently use HENS for submitting all Preadmission Screenings (PASS) or Resident Reviews (RRs).  ODM has stated that they will be releasing written guidance as well as state-sponsored training later this summer.

QIT Update
ODM is still on track for an August 1, 2016 effective date for the Disability Determination Redesign (DDR) conversion and Ohio Benefits implementation.  Kim Donica, Chief, Long-term Services and Support shared that ODM is still waiting for CMS approval of the overall Disability Determination Redesign (1634) State Plan Amendment (SPA) including the 1915(i) and 1915(c ) waivers.  However, approval for ancillary components are coming in.  CMS approval is based on a sequencing of items and CMS has received the signed agreement from the Social Security Administration to use their data.  Donica shared that ODM used the “off the clock” time period to have informal discussions with CMS so now that they are “on the clock” they should be on path for approval.  In addition, ODM is working on FAQs for facilities specific to QITs that should be available by the end of next week.

Key highlights include:

• Individuals who apply for Medicaid prior to August 1 under current 209(b) rules, and who receive their approval after August 1, the “pending” Medicaid LTC individuals, will not need a QIT until their next redetermination.
  
  
• If an individual’s income changes and puts him/her over the special income limit (SIL) of $2,199, the individual will need a QIT to meet Medicaid eligibility requirements. They will have a grace period after the county department of job and family services notifies them of the potential termination of eligibility during which they will to need meet the QIT requirements.  However, a person who is already over the SIL and benefits from the grace period will not stop the grace period a change in income.  The requirement to place income over the SIL into a QIT account is applicable even for people on restricted Medicaid and for Medicaid beneficiaries who are in a skilled stay.
  
  
• County caseworkers will be instructed by ODM to deduct the $15 allowance for bank/administrative fees for QIT accounts before calculating patient liability. ODM is revising the administrative rule on patient liability to reflect this information.
  
  
• ODM is developing a mechanism for approval of trust fees that exceed $15 for individuals using a bank to hold their QIT account and a certificate of trust document to explain the trustee’s powers to the bank.
  
  
• A power of attorney (POA) that includes language that permits the POA to enter into a trust on behalf of the individual authorizes the POA to sign a QIT.
  
  
• ODM is going to be talking with the Supreme Court Guardianship Committee for guidance on how to handle the group of individuals with cognitive impairments who do not have a power of attorney.
  
  
• AHS is prioritizing those individuals who will have their redeterminations starting in January. In addition, AHS will prioritize those individuals who apply for Medicaid LTC after August 1 and are over limit with establishing a QIT.
  
  
• For approximately six weeks after "going live", county workers will have access to “hypercare” which will offer county workers live access should they need assistance with issues.

Questions or comments regarding the information highlighted above can be directed to LeadingAge Ohio's Director of Advocacy, Nisha Hammel, at nhammel@leadingageohio.org or call 614-545-9026.