DOH Nursing Home Acuity Workgroup Meeting - January & July 2019 Rates

Nancy Levielle and Carl Pucci Stephen Hanse in Finance & Reimbursement

DOH held the first of three planned meetings of the Nursing Home Acuity Workgroup today. The Workgroup was established pursuant to the 2019-20 Enacted State Budget, and includes representatives from Statewide Associations, nursing homes and other Case Mix experts.

In its charge, the goal of the Workgroup is to “promote a higher degree of accuracy in the Minimum Data Set data, and target abuses in developing such recommendation.” The Workgroup shall ensure that the collection process and related CMI adjustments recognize the appropriate acuity for nursing home residents.

DOH issued a DAL on 9/17/18 (attached), indicating their plans to collect data for two census dates (April 25 and July 25, 2018). Subsequent data analysis revealed significant downward CMI swings when comparing the April 2018 data (1.017) (unannounced non-look back period) to both the January (1.309) and July 2018 (1.300) data (announced look back periods). This led DOH to seek improvement in future practices regarding “accuracy” in the MDS collection process, via the Workgroup recommendations. 

January 1, 2019 Rates 

At today’s meeting, DOH announced that they are “recommending” that the pending January 1, 2019 rate utilize only the July 2018 MDS data, following past practices. 

July 1, 2019 Rates – New Methodology 

However, for the upcoming July 1, 2019 rates, DOH indicated that the census roster is no longer required, and that DOH will use all available MDS assessments. Consequently, all provider MDS submissions from 8/8/18 through 3/31/19 will be used for the case mix adjustment to the 7/1/19 rates. In addition, the 5% CMI Cap previously utilized with respect to OMIG MDS audits will be lifted. As such, there will be no 5% floor or ceiling for Case Mix retroactive adjustments. DOH indicated this new methodology may result in $122M in state share savings. 

Among other things, NYSHFA strongly emphasized the rules of the MDS submission process. During the rate setting period for the past 10 years, SNF’s have been able to look at the DOH census timeframe and lookback dates prior to assessing their MDS schedule. This allowed the SNFs to do an extra quarterly MDS or set the schedule for their quarterly MDS to capture provided services that may not otherwise be captured. Extra quarterlies and flexibility of the MDS schedule is allowable by CMS. By eliminating the census and lookback date, a SNF misses this allowable opportunity. 

Pursuant to DOH’s proposed process for 7/1/19 rates, a SNF must guess the timeframes for the look back. Examples of what could be missed in this proposed method is when a SNF provides IV therapy with antibiotics for a few days to prevent a hospitalization or provides therapy for a resident who had been ill short term to assist recovery. If both situations fall early in the timeframe before the quarterly is due and an additional MDS is not completed at that time, it will never be captured for rate setting purposes. Completing an MDS is a complex process conducted by an RN and the interdisciplinary team. Adding guesswork into the system requires additional workload to our already stressed workforce. In addition, the clinical staff has less time for providing actual care. 

NYSHFA also addressed the term “accurate” MDS and reducing abuse of information. The nurse must attest to each MDS. DOH’s fluctuations over the rate setting quarters vs the non-rate setting quarters are due to the reasons noted above. The SNFs are providing accurate MDS to CMS each time they submit to the best of their ability. We stressed the need to remove that term as it does not reflect the work they are conducting.

NYSHFA has been in contact with legislative leaders, the Governor’s office, DOB and our General Counsel regarding this issue. We will keep members updated as the matter progresses.


Stephen B. Hanse, Esq.
President & CEO
518-462-4800 x11

Nancy Leveille, RN, MS
Executive Director
518-462-4800 x20

Carl J. Pucci
Chief Financial Officer
518-462-4800 x36