Medicaid Reimbursement & CON Update Pete Van Runkle - PDF document

10/11/2019 Medicaid Reimbursement & CON Update Pete Van Runkle pvanrunkle@ohca.org 614-361-5169 Waiver Reimbursement in HB 166 • Legislature approved 5.1% increase for assisted living, personal care services in PASSPORT • Legislature approved market-basket increases for both of above, starting in SFY 2022 • Legislature appropriated $40 million for these increases for biennium • Governor DeWine vetoed the statutory language 1

10/11/2019 Waiver Reimbursement: Administration Proposal • Administration said legislature did not appropriate enough money to cover the 5.1% increases intended by the legislature (MyCare Ohio left out) • Administration proposed 3.25% increases, to be done by rule • Assisted living plus personal care in PASSPORT, Ohio Home Care, and MyCare waivers (not state plan home care) • Administration considering emergency rules to make increases effective immediately • Stakeholders: how can we get to the 5.1% intended by legislature? • We estimate it would require $22.8 million more • Through first two months of fiscal year, Medicaid spending $53 million under budget (remember that number) Medicaid and PDPM • PDPM eliminates many of the Medicare PPS assessments, allows states to use Optional State Assessment (OSA) indefinitely for RUGs • Ohio does not use PPS assessments to set Medicaid rates for its RUGs system (with a couple of exceptions) • Ohio does not need OSA and is not using it – continuing with OBRA assessments (per updated ODM FAQ) • Certain rule provisions conflict with assessment changes, most notably requirement to combine admission and 5 or 14-day assessments • ODM PDPM fact sheet says SNFs can ignore this rule until changed 2

10/11/2019 Future Questions • When will CMS remove items from OBRA assessments needed to calculate RUGs? • What does CMS mean by “supporting RUGs”? • ODM hiring contractor to develop new Medicaid system • RFP is on the street • Bids due by October 22, selection finalized December 9 • “[P] rovide expertise in the area of Nursing Facility (NF) Medicaid rate development processes under new methodologies” • Needed because “CMS has notified State Medicaid agencies that CMS will no longer support RUGs IV after 9/30/20” HB 166 and SNF Reimbursement • Legislature provided for 2.4% market-basket increase July 1-December 31, 2019 • Legislature converted this into quality incentive payment averaging 2.4% January 1-June 30, 2020 • Legislature increased quality incentive to 2.4% + FFY 2020 market basket (also 2.4%) July 1, 2020-June 30, 2021 • Legislature reinstated market-basket statute effectively starting July 1, 2022 (after rebasing in SFY 2022), excluding tax and $16.44 components • Governor DeWine vetoed second-year quality increase, effective date of exclusions from market basket, renovation exception to occupancy penalty 3

10/11/2019 Rationale for Vetoes • Legislature did not appropriate enough money to cover increases • Language of bill required greater payout than estimated • Renovation language was unclear • Administration opposed to market basket at all times and in all places As-Is State After Vetoes • June rates paid for first 17 days of July (relates to interim budget (SB 171), also applies to CHOPs during period per rule 5160-3-65.1) • Market-basket increase in effect July 18-October 16 • Veto moves effective date of removing taxes and $16.44 component from market basket up to October 17, so market-basket increase reduced from October 17-December 31 • Quality incentive averaging 2.4% January 1-June 30, 2020 • Quality incentive averaging 2.4% July 1, 2020-June 30, 2021, with occupancy penalty but without renovation exception • We estimate $149 million instead of $229 million under HB 166 4

10/11/2019 Example of October 17 Rate Change • Sample rate calculation as of July 18, 2019: 119.07 59.06 8.18 2.06 16.83 -1.79 0.00 2.10 205.51 • Sample rate calculation as of October 17, 2019: 119.07 59.06 8.18 2.01 16.44 -1.79 0.00 2.10 205.07 • ODM says they will post new rate letters for this change, expecting by end of this week • October billing will require two detail lines, as was the case for July Budget Corrective Legislation – Not Final • Administration agreed to provide full funding intended by legislature (actually $238 million) • This would be done by increasing average quality incentive percentage to 5.2% for SFY 2021 • In exchange, provider associations agreed to eliminate all statutory language about market basket and stop the quality incentive after SFY 2021 • Rebasing for SFY 2022 untouched – continuation of quality incentive and its structure to be negotiated for next budget in context of rebasing • Both reductions - for first 17 days of July and for October-December 2019 – to remain in effect • Request for additional $37.6 million appropriation from legislature • Renovation exception language would be restored in revised fashion • To be enacted by legislature in corrective legislation (to be determined) 5

10/11/2019 CHOPs & New Buildings Excluded • Administration opposes any quality incentive to a center that experienced a CHOP starting 2018 forward unless the center has full calendar year of quality data under the current provider (change from historical approach) • For example: • January 1 quality incentive will be based on data for CY 2018, so a center that had a CHOP in 2018 or 2019 will not have a full year of quality data under the new provider in 2018 • July 1 quality incentive will be based on data for CY 2019, so a center that had a CHOP in 2018 could qualify, but not a center that had a CHOP in 2019 • As with the occupancy penalty, the money “saved” by not paying a quality incentive to a center with a CHOP will be redistributed to qualifying centers • Applies to new buildings coming on line during 2018 or 2019 • Cuts off quality incentive to any center that CHOPs within a fiscal year (i.e., between January 1, 2020, and June 30, 2021) – this money will not be redistributed New Quality Incentive - Points • Completely separate from “old” quality incentive – old incentive will continue in parallel with “new” incentive, although measures revised for July 1, 2020 • Four quality measures for new incentive • Long-stay pressure ulcers • Urinary tract infections • Catheters • Ability to move worsens • Publicly available CMS data for preceding calendar year – four-quarter average • CMS-assigned point values (see 5- Star Technical Users’ Guide April 2019) • Divide CMS points by 20 • Default lowest group for each measure to zero points • Sum points across 4 measures 6

10/11/2019 Quality Measures Data – CY 2018 https://data.medicare.gov/ or Google “CMS Medicare data” 7

10/11/2019 Nursing Home Compare Archived Data • Scroll down to “2018 Annual Files” and download zip file • Open folder and open “Four_Quarter_AVG_MDS_QMs_ME_to_WY_2018.csv” • Search your building by Medicare provider number • Scroll to or search relevant QMs • Note “2018Q4” number in column G • Compare this number to cut points • Note: cut points are shown as decimals, numbers in NH Compare data are shown as percentages 2019 Quality Data • Same data source (CMS Nursing Home Compare/Five-Star) • Same measures and cut points • Final quality data will not be available until spring 2020, but can be estimated now 8

10/11/2019 Table of Cut Points from Users’ Guide Ability to Move Pressure Ulcers UTIs Catheters Points 0.0821 0.0377 0.0070 0.0050 150/100 0.1121 0.0584 0.0160 0.0126 135/80 0.1350 0.0783 0.0272 0.0217 120/60 0.1568 0.1057 0.0452 0.0356 105/40 0.1760 >0.1057 >0.0452 >0.0356 90/20 0.1955 75 0.2153 60 0.2394 45 0.2747 30 >0.2747 15 9

10/11/2019 New Quality Incentive: Value Per Point • Quality incentive pool • Percentage of each SNF’s base rate (2.4% for January 1, 5.2% for July 1) • Base rate = direct, ancillary/support, capital, taxes, $16.44 add-on • Multiply by Medicaid days • Sum for all centers • Quality point days • Sum points for all centers • Multiply by Medicaid days • Divide pool by point days • Current OHCA rough estimates • Around $0.41 per point for January 1 • Around $0.90 per point for July 1 Example – January 1, 2020 • Facility X has long-stay pressure ulcer percentages in CY 2018 as follows: Q1 Measure Q2 Measure Q3 Measure Q4 Measure Four Quarter Score Score Score Score Average Score 17.30769 17.3913 14.63415 22.22222 17.71428 • Cut points from Technical User’s Guide: • Facility X’s score is in the 20 -point range 10

10/11/2019 Example – January 1, 2020, cont. • Divide points (20) by 20 = 1 • Facility X is in lowest percentile, so it defaults to 0 points • Let’s assume the following points on the other QMs: Pressure ulcers Catheters UTIs Ability to Total move 0.0 4.0 4.0 7.5 15.5 • Let’s assume the value per point is $0.41 • Facility X’s new quality incentive payment is 15.5 * $0.41 = $6.36 in addition to old quality incentive payment Example – January 1, 2020 cont. • Let’s assume Facility X’s rate as of December 31 is $202.12, with $4.71 of that being the market basket • Let’s also assume Facility X’s CMI does not change • Rate calculation: • $202.12 - $4.71 = $197.41 (stripping off market basket) • $197.41 + $6.36 = $203.77 (adding quality incentive) 11