2018 VBP Reporting Requirements Technical Specifications Manual Update The NYS Dept. of Health has updated the 2018 Value Based Payment (VBP) Reporting Requirements Technical Specifications Manual. The purpose of this document is to make stakeholders aware of the quality measure reporting requirements for Medicaid Managed Care Organizations participating in the New York State Medicaid VBP program, and its contents include an overview of the specific reporting requirements for Category 1 measures for each VBP arrangement, a description of the changes to the measure sets from Measurement Year 2017 to 2018, and detailed instructions regarding additional file specifications required for the VBP program. The changes added include a field that identifies the VBP Contractor Tax Identification Number (TIN) for each member attributed to a VBP arrangement. Please direct all questions to the NYS Dept.of Health at email@example.com.
Legislative Mandates Restricting Uses of Federal Grant Funds Earlier this year, HRSA released Grants Policy Bulletin 2018-04 to ensure health center policies and procedures adequately incorporate HHS legislative mandates that govern the use of HRSA awards. These mandates were reiterated in the February 2018 legislation reauthorizing the Health Center Fund. The recent OMB 2018 Health Center Program Compliance Supplementalso includes procedures auditors use to review compliance with legislative mandates that limit the use of funds on HRSA awards. NACHC has provided health centers with a sample Policy and Procedure to address these Legislative Mandates. For more information and links to download the policy and procedure, click here.
State Decreases PCMH Incentive Payment Rates Effective May 1, 2018, the State has changed the reimbursement amounts for providers working at practices that are recognized as a Patient-Centered Medical Home (PCMH) by the National Committee for Quality Assurance. The revised policy applies to both Medicaid Managed Care and Medicaid Fee-For-Service. Additionally, PCMH incentive payments will not be tied to VBP participation and quality this year, as previously thought. For more details, clickhere.
Social Determinants of Health Innovation Applications Now Available The NYS Dept. of Health (DOH), Office of Health Insurance Programs (OHIP), Bureau of Social Determinants of Health is launching a new initiative to identify innovative ideas to effectively address the Social Determinants of Health (SDH) for Medicaid members across New York State. The intent of this Call for SDH Innovations is to solicit input from interested parties across the state and around the country. Submissions will be reviewed by a team of health care experts identified by DOH. Top innovations will receive special recognition but all innovations, with the consent of the submitting organization, will be shared publicly by DOH.
Later this fall, DOH will host a SDH Innovation Summit during which the applicants with the best solutions will pitch their products and ideas to a panel of expert judges and audience members. It will be a chance for top health care professionals and investors who are focused on driving transformational change to hear new and exciting proposals for improving health outcomes for millions of New Yorkers on Medicaid. At the Summit, winners in each category will be honored with 2018 SDH Health Innovation Awards.
While there is no funding from the State available for this initiative, it is a chance for innovative companies and organizations to receive exposure to key health care decision makers including, but not limited to, healthcare providers, Managed Care Organizations, and DSRIP Performing Provider Systems.
The submission deadline is June 15, 2018 at 5:00 p.m. Contact SDH@health.ny.gov with any questions.
HRSA Releases RFA for $10M in Capital Grants for School-Based Health Centers HRSA has released an RFA for $10M in capital grants for school-based health centers. Applications must be submitted via Grants.gov by April 17, 2018. The purpose of the School-Based Health Center Capital (SBHCC) program is to increase access to mental health, substance abuse, and childhood obesity-related services in operational school-based health centers by funding minor alteration/renovation projects and/or the purchase of moveable equipment, including telehealth equipment. For more information and to access the RFA, clickhere.
OMIG Releases Revised Protocols for Diagnostic and Treatment Centers The Office of the Medicaid Inspector General recently released revised audit protocols for Article 28 Diagnostic and Treatment Centers. These revised protocols condense and streamline previous protocols and add reference citations. Access themhere.
Service Authorization and Appeal Changes for Medicaid Managed Care The NYS Dept. of Health’s Office of Health Insurance Programs (OHIP) will implement several important changes related to Medicaid managed care service authorization, appeals, fair hearings and grievances (complaints) as required by the Center for Medicare and Medicaid Services Medicaid and Children’s Health Insurance (CHIP) Programs Final Rule published May 6, 2016, amending federal rules at 42 CFR Part 438. These are major changes affecting the majority of New Yorkers enrolled in the state’s Medicaid managed care programs, and they apply to New York’s mainstream Medicaid managed care, Health and Recovery Plans, HIV Special Needs Plans, Managed Long-Term Care Partial Capitation, Medicaid Advantage, and Medicaid Advantage Plus.OHIP will host a free informational webinar for providers, community representatives, and enrollees to learn more about the new appeals process on the following dates:
The same information will be shared on both dates. The session will also be recorded and posted online at a later date.
The informational webinar will review the new requirements for service authorization requests, appeals, and complaints. Starting on May 1, 2018, plans will be required to complete review of service authorization requests under different time frames, issue revised enrollee notices, and, for adverse determinations made on May 1, 2018 and thereafter, follow revised appeal processes. Although there are several changes, two key provisions are:
Starting with plan service determinations made on May 1, 2018 and thereafter, enrollees wishing to dispute a plan’s adverse determination regarding their services must exhaust the plan’s internal appeal process before requesting a State Fair Hearing. This means the enrollee must request a plan appeal, which may be expedited, and receive a Final Adverse Determination upholding the plan’s decision prior to requesting a State Fair Hearing. Enrollees will have 120 days from the Final Adverse Determination to request a State Fair Hearing. If the plan does not respond to the Plan Appeal or the response is late, the appeal process will be deemed exhausted and the enrollee may request a State Fair Hearing.
Upon review, health plans may determine to reduce, suspend or terminate authorized services. The enrollee’s aid from the plan may be continued once the enrollee has filed a plan appeal (within 10 days of the Initial Adverse Determination notice, or before the effective date of the decision, whichever is later). If the plan upholds its decision and issues a Final Adverse Determination, the enrollee may have the enrollee’s aid may be continued once the enrollee has requested a State Fair Hearing (within 10 days of the Final Adverse Determination notice, or before the effective date of the decision, whichever is later). If the enrollee loses the plan appeal or Fair Hearing, it may be necessary to pay for the services received while the appeal/fair hearing was being considered.
NYS Dept. of Health Resumes Opt-Out Mailings to Medicaid Members The NYS Dept. of Health will resume a mailing this month to new Medicaid members to explain the Delivery System Reform Incentive Payment (DSRIP) program´s statewide efforts on healthcare system change and how Performing Provider Systems (PPS) use Medicaid data to improve patient care. The letter will also review the option to not have the member’s data shared by the PPS with provider partners, known as “opting out.” The last mailing of this nature took place in August 2016 and did not continue due to vendor procurement processes. Any new members since that time have been automatically opted out until a new mailing to notify them of the choice to opt-out could be completed. This new mailing will begin the week of February 19, 2018. Approximately 2 million Opt-Out letters will be sent to Medicaid members who became eligible since August 2016. Smaller mailings to new members as they become eligible for Medicaid will continue on a monthly cadence through 2019.
PPSs are responsible for working to improve health outcomes for their Medicaid members, who are seeing the physicians and providers in the PPS. Data sharing of available Medicaid information is key for effective collaboration among the lead PPS and related network partners for providing and coordinating services to Medicaid members. Data-sharing is very important to getting services to patients and in achieving quality performance and clinical outcomes.
If a Medicaid member agrees to data sharing within the DSRIP program, he/she does not have to take any action and, except for claims related to substance abuse diagnoses and treatment, his/her data will be shared with the PPS. There have been no changes made to how a Medicaid member seeks care or to Medicaid member benefits. If a member chooses to opt out, he/she must sign and return the form sent in the mail or call the Medicaid DSRIP Opt Out Helpline at 1–855–329–8850.
Please see below for important information to help explain DSRIP data sharing and Opt Out:
Click here to access copies of the Opt Out Letter and accompanying form in English, Spanish and 18-Point Font.
A webinar and accompanying slide deck explaining Opt Out is available here.
The Medicaid call center is open to receive questions regarding the content of this DSRIP mailing: 1–855–329–8850.
VBP Bootcamp Materials Now Available Online The NYS Dept. of Health has posted all VBP Bootcamp materials, including the webcast recording of the Albany Bootcamp session, all course presentations, and supplemental materials.on its website. Information regarding additional VBP University semesters will be released in the near future. In the meantime, please continue to complete semesters 1-3 and corresponding quizzes to receive a certificate of completion. Certificates will be sent via email on a quarterly basis. Remember to keep the VBP conversation going online by following @NewYorkMRT on Twitter and using the hashtag #NYSLearnsVBP in your social media posts. Please send any questions to VBP@health.ny.gov.
NYS Dept. of Health Announces Availability of Statewide Health Care Facility Transformation Program II Funding On January 8th, the NYS Dept. of Health announced the availability of funds under the Statewide Health Care Facility Transformation Program II. A total of up to $203,782,888 is available through Request for Applications (RFA) #17648 to health care providers that are deemed by the Commissioner to fulfill or will fulfill a health care need for acute inpatient, outpatient, primary, home care or residential health care services in a community. A minimum of $46,995,507 of this total amount is available for community-based health care providers, which are defined as diagnostic and treatment centers, mental health and alcohol and substance abuse treatment clinics, primary care providers and home care providers. Applications must be submitted in Grants Gateway no later than 4:00 p.m. EST on Wednesday, March 14th. An informational Applicant Webinar will be held on Wednesday, January 31st from 10:30 a.m.-12:00 p.m. To register, click here. Questions regarding the Statewide Health Care Facility Transformation Program II are due by February 9th and should be submitted via e-mail to Statewide2@health.ny.gov.
Recent VBP Social Determinants of Health Webinar and Materials Materials from the NYS Dept. of Health’s August 25 webinar on VBP Social Determinants of Health and Community Based Organizations are now online here. These include a PDF copy of the webinar deck, the live recorded video of the webinar, the Empire Supportive Housing Intervention Video, God’s Love We Deliver Intervention Video and the Social Determinants of Health Intervention Template. Items mentioned during the webinar that the DOH is working to release in the near future include:
Further guidance related to Tier 1 CBOs, including a listing of New York State Tier 1 CBOs
Release of a Q&A document related to VBP SDH and CBOs based on the questions received before and during the webinar
The First 1,000 Days on Medicaid On July 20th, Medicaid Director Jason Helgerson announced a new focus for Medicaid redesign in New York: The First 1,000 Days on Medicaid initiative. “Those first few years are so important,” said Helgerson. “If we do a better job of trying to influence the lives of our youngest children, we can prevent so much cost, so much misery, so many problems in the future.” The First 1,000 Days on Medicaid initiative will be a collaborative effort, bringing together stakeholders in a series of four work group meetings between August and October. The work group will be charged with developing a ten point agenda to focus on enhancing access to services and improving outcomes for children on Medicaid in their first 1,000 days of life.
The First 1,000 Days on Medicaid work group will chaired by the Chancellor of the State University of New York, Nancy Zimpher, a national leader in educational issues and cross-system collaboration. Vice chairs will be Kate Breslin, President and CEO of the Schuyler Center for Analysis and Advocacy, and Jeffrey Kaczorowski, MD, Senior Advisor, The Children’s Agenda, and Professor of Pediatrics, University of Rochester. The group will be built off the successful work and membership of the Value Based Payment Advisory Group on Children’s Health. Other partner organizations will include the United Hospital Fund, Center for Health Care Strategies, and The Albany Promise.
Helgerson’s announcement was made at the United Hospital Fund’s annual Medicaid conference, and can be found here. The first meeting of the group will take place in early August.
VBP University The NYS Dept. of Health has launched VBP University, an online, educational resource designed to raise awareness, knowledge and expertise in the move to Value-Based Payment. VBP University combines informational videos and supplemental materials that stakeholders can use to advance their understanding of this massive transformation effort. Click here to watch NYS Medicaid Director, Jason Helgerson present an overview of the curriculum. Additional information is available here.
2017 VBP Quality Measures Now Online The NYS Dept. of Health has updated the DSRIP – VBP Resource Library to include the VBP Quality Measure Sets for Measurement Year 2017 for the following VBP Arrangements:
Total Care for the General Population/Integrated Primary Care (TCGP/IPC) Quality Measure Set
Health and Recovery Plans (HARP) Quality Measure Set
The measure sets provide a high-level overview of the process for measure set development as well as the listing of measures for the 2017 Measurement Year, and they include all Category 1 and Category 2 measures for use in contracting between Managed Care Organizations and VBP Contractors E-mail DSRIP@health.ny.gov with any questions.
CMS Approves VBP Roadmap Update The Centers for Medicare & Medicaid Services (CMS) has approved the State’s annual update to the Value Based Payment (VBP) Roadmap. The most up-to-date version of the Roadmap may be viewed here.
NYS Dept. of Health Releases Integrated Care Workgroup Final Report New York State’s Integrated Care Workgroup (ICWG) released its final report in late December. This report summarizes the work of the ICWG, charged with designing a statewide model for primary care referred to as Advanced Primary Care (APC), over the past year and a half. To access the report,click here.
NYS Dept. of Health Finalizing Provider Contract Guidelines The NYS Dept. of Health is in the process of revising its Provider Contract Guidelines for MCOs, IPAs and ACOs to reflect value-based payment arrangements. It is expected that the final version of the Guidelines will be released within the next few weeks. In the meantime, click here to access the most recent draft.
DOH Releases Shared Space and Co-Location Guidance The NYS Dept. of Health (DOH) recently releasedguidance on shared space and co-location arrangementsbetween two or more providers. Please take a look and contact Lacey Clarke with any issues or comments you may have. CHCANYS is continuing its work to ensure that FQHCs are able to easily create integrated care models, and your feedback will assist us in our ongoing conversations with DOH on this issue.
CMS Approves LARC Reimbursement for NYS FQHCs The Centers for Medicare and Medicaid Services (CMS) recently approved the NYS Dept. of Health’s (DOH)State Plan Amendmentseeking to carve out reimbursement for long-acting reversible contraceptive (LARC) devices from the FQHC PPS rate. Once guidance has been published in the Medicaid Update, FQHCs will be able to receive reimbursement for the acquisition cost of LARC devices in Medicaid retroactive to April 1, 2016. In order to receive reimbursement, an FQHC must be enrolled as an order ambulatory provider. DOH is currently drafting implementation and billing procedure details, which they anticipate will be included in the September Medicaid Update.
New Legislation Enacted to Limit Initial Opioid Prescribing to a 7-Day Supply for Acute Pain To further reduce overprescribing of opioid medications, effective July 22, 2016, initial opioid prescribing for acute pain is limited to a 7-day supply per New York State Public Health Law section 3331, 5. (b), (c). Click here for additional details on this legislation recently shared by the NYS Dept. of Health.
New SNAP Time Limits Leave Vulnerable New Yorkers Without Food Assistance Thousands of New York State residents began losing SNAP benefits in June due to a federal rule that places a limit on how long certain unemployed, childless adults referred to in federal regulations as able-bodied adults without dependents (ABAWDs) are eligible to participate in SNAP. Under the time limit rule, those considered ABAWDs may only receive SNAP benefits for a total of three months in a 36-month period, unless they live in a waived area, meet an exemption, or are already meeting work requirements.
Medical professionals can help maintain benefits for those who are affected by this rule, but may be unable - or “unfit” - to work, by documenting a medical condition that limits an individual’s ability to meet the work requirement.
Those at risk of losing benefits include SNAP recipients who are between 18 and 49 years old, are not certified as disabled, do not have children under 18, and are not working at least 20 hours a week. These are particularly vulnerable individuals with limited earning potential, low job skills, transportation or language barriers, and limited access to medical services. Many of the people who fall into this group can’t work 20 hours a week, due to an undocumented temporary or permanent physical or mental condition.
Medical professionals can help these individuals to keep needed SNAP benefits by documenting their condition on a medical statement (with FAQ for Medical Providers)created by Hunger Solutions New York, a statewide anti-hunger organization. This form is designed as a template, but any medical statement signed by a healthcare provider should be accepted by most SNAP offices. The standard of unfitness for exemption from the SNAP time limit does not require a diagnosis or medical records.
Patients with a reduced ability to work who qualify for this exemption include those who have difficulty maintaining focus and concentration for two hours at a time, including difficulty with consistently remembering and carrying out tasks.
Others who qualify have mild or moderate anxiety, depression or a maladaptive personality that reduces their ability to work 20 or more hours a week. The symptoms do not need to be “marked” or “severe.”
Also qualifying for the exemption are people who have a physical condition that limits them to light or sedentary work, who cannot stand or walk for extended periods of time, or who cannot engage in physical labor on a sustained basis.
Healthcare professionals simply need to fill out and sign a medical statement to verify that a patient has a reduced ability to work based on his or her condition. The form is then returned to the patient to provide to his or her local SNAP office.
A variety of professionals can sign the form, including: a doctor, doctor assistant, representative of the doctor’s office, a nurse, nurse practitioner, licensed or certified psychologist or social worker.
More resources for helping people considered ABAWDs are available on Hunger Solutions New York’s website. They include a fact sheet, a checklist to screen for exemptions, a flyer for SNAP recipients, a sample medical statement with frequently asked questions for providers, and more.
If you have a patient who needs help understanding how SNAP time limit rules apply, here are some additional resources:
To find the local SNAP/HRA office in your community: Outside New York City, dial 800-342-3009 In New York City, dial 311.
Nutrition Outreach & Education Program (NOEP) provides assistance with SNAP applications or more information about SNAP time limits for individual clients. To find a local NOEP Coordinator, go to FoodHelpNY.org.
VBP Regional Bootcamp Learning Series The NYS Dept. of Health (DOH) has launched a Value-Based Payment (VBP) Regional Bootcamp Learning Series in an effort to ensure a successful transition to VBP implementation. Geared toward all parties planning to implement Medicaid payment reform but designed specifically for those with little to no experience in executing value-based contracts, the bootcamp series is open to the public free of charge and will take the form of three all-day sessions in each region. Scheduling information, training agendas and additional details are available on DOH’s new VBP Bootcamps web page.
NYC Mayor Releases Plan for Strengthening and Transforming Health + Hospitals Last week, NYC Mayor Bill de Blasio released a new report outlining strategies for strengthening and transforming the Health + Hospitals health system and for addressing a FY16 operating gap currently projected at $600 million. To access the report, click here.
Update: Wrap for Essential Plan Members The NYS Dept. of Health (DOH) has become aware of an issue preventing FQHCs from billing the supplemental payment rate (rate code 1609) for the Aliessa population (former Medicaid) enrolled in the Essential Plan (EP). DOH is working with CSC to add rate codes 1609, 4026-4028 to a bypass edit which will allow these claims to pay. This edit will be effective from April 21, 2016, at which time providers will able to submit or resubmit claims for these rate codes for EP Aliessa members retroactive to January 1, 2016 by utilizing delay reason code 3. Please contact firstname.lastname@example.org with any questions.
Value Based Payments (VBP): An Introduction The NYS Department of Health recently announced the release of “Value Based Payments (VBP): An Introduction,” a video available in both English and Spanish that explains what value based payments are, the important role that they play within the NYS Medicaid program, and how they will help improve patient outcomes. To access the English version, click here. To access the Spanish version, click here.
PCMH Rate Changes Delayed Thanks to our advocacy efforts and collaboration with the Primary Care Development Corporation, the NYS Department of Health has announced that they will delay the rate reductions for Patient-Centered Medical Home recognition under the 2011 NCQA standards until January 2016 instead of April 1, 2015, as previously proposed. Payments for PCMH 2014 standards will be increased as of January 2016.
The delay in rate reductions for PCMH 2011 will give FQHCs the extra time necessary to achieve the 2014 standards and will ensure that health centers are able to continue providing high quality community-based primary care services.
More detailed information on the new PCMH rates, to be implemented in January 2016, is available here.
CHCANYS is on Facebook! CHCANYS is now on Facebook – follow our page for important announcements and links to articles of interest to New York’s FQHCs. Have a photo or a story to share? Send it our way so that we can help spread the word to our online community. Contact Kate Graetzer at email@example.com with your contributions and feedback.