J. Brandon Durbin 2950-50th Street 909-18 th St. Lubbock, Texas 79413 Plano, Texas 806-791-1591 469-361-0120 Fax 806-791-3974 brandon@dhcg.com brandon@durbinco.com
Changed with the Waiver Mostly Managed Care Traditional is a very small part of Rural Medicaid No Cost settlement on Managed Care Rider 38 hospitals have some protection
Rider 38 Hospitals Hospitals in counties less than 60,000 in 2010 Sole Community Hospitals Rural Referral Hospitals Critical Access Hospitals Based on a historical based SDA Better than urban, which is based on 53% of cost Plus certain incentives Trauma, Wage Index, etc.
Decreased Utilization = Reduced Cost Mainly patient driven Concern on data from managed care to HHSC Used in DSH/ UCC Used in future rate setting? How do we set future rates? No accurate cost data Big question for the future
Outpatient is where the biggest loss occurs in both traditional and managed care Will inpatient, with declining utilization and payment methodology, also result in losses? Rider 38 establishes that rural providers will have a separate or modified payment for outpatient services under EAPG s Never did get relief from the clinical v. ER visit issue
Renewal We are already ½ way through this 5 year waiver Renewal is to be submitted by September 30, 2015 The money is way behind 18% of entire DSRIP paid to date DSRIP paid only $2.1B to date $500M for submission $1.6B in DY2 metrics out of $2.3B allocation for DY2 UCC partially paid DY2 funding with hopes of more late DY3 Basically a year behind
CMS does not like UCC Feels that Medicaid Expansion could have solved this issue Pressure to expand-shift dollars, Winner/Losers Cheaper to CMS than expansion But does not progress Obama s plan The ACA will reduce UCC as patients will be covered, but due to high deductibles, they will still be basically uncompensated They do not Count!!!
300+ Performing Providers as of 12/31/2013 224 Hospitals 18 Physician groups 39 LMHA 20 Health Departments As of December 31, 1258 approved projects 234 submitted 3-year projects April / October reporting April was just released IGT / Payments in July and January September 2014 Statewide Learning Collaborative
Where did the DSRIP dollars go? (Based on initial submissions) State 4.2% Private 44.6% Transferring 40.2% Other Public 8.5% Ector / Lubbock 2.5%
Other Publics had $588M in initial share of DSRIP Other Public includes some smaller urban (Community Hospitals) Some Rural is in the Private Section
DSH for 2013 is still incomplete due to Texas Children's lawsuit Lawsuit is regarding Federal rules on calculating HSL for dual eligible patients Only applies to dual eligible with 3 rd party coverage Pass 3 was probably a one time program Did assist rural publics, under the 2013 UCC Haircut Cash flow was also improved due to timing
DSH 2014 was proposed in a model last week Months of meetings and negotiations THA & HHSC Rider 86 Authorized State GR for DSH Requires that DSH & UC be fairly allocated among all classes of hospitals Requires report to LBB before funding DSH for 2014 Expected timeframe - August / September?
HHSC Proposal Funds DSH through State GR and IGTs Rural Public will have to fund ½ of the IGT necessary for the funds After also sharing the State GR, the ½ is 16.7% effective IGT, paid for by Large Publics Rider 38 public hospitals, $40.8M DSH, $6.8M IGT All DSH funds are being used Pass 3 is still part of the rules, but no capacity remains
Rural Private 2% Where will 2014 DSH dollars go? (Net of IGT - Proposed) State 15% Transferring 20% Private 57% Other Public 4% Ector / Lubbock 2%
THA Model was released in March HHSC Model was released last week Main difference in the HHSC revision was to allocate UCC based on hospitals HSL limits HSL is Hospital UCC, and is federally defined Physician Clinic & Pharmacy (PCP) was an additional UCC, unique to the Waiver Three pools; Large Public, Small Public, and Private
UCC Allocations & Haircuts HSL based haircut has a 28.2% haircut from global capacity. All public providers fully fund their respective allotment Privates have to find IGT sources Compared to 2012 funding Rural Public would have a 24% reduction Large Urban a 22% reduction Privates an 8% gain
2014 Proposed v. 2012 Actual $2,500,000,000 $2,000,000,000 $1,500,000,000 2012 Funding $1,000,000,000 2014 Proposed Allotment $500,000,000 $0 Large Public Small Public Private
TORCH Requested Changes Allow Rider 38 hospitals to achieve full HSL funding Moves the Private gain down 1% point Also allow Rider 38 Privates, an HSL allocation preference Would allow all Rider 38 hospitals to maximize funding to HSL Justified in that many Rural providers did not have DSRIP to offset the losses in UCC payments, like others Large Public still do not like IGT for others Midland & Nueces are major issues to them
Private 67% Where will 2014 UCC dollars go? (Gross Based on HHSC Proposal Other Public 4% Ector / Lubbock 2% Transferring 27%
Various Private Issues One of the purposes of Rider 86 was to encourage Burden Alleviation models There will be competition due to capacity; and due to new IGT; South Texas, University Systems, etc. Very limited private capacity left to fund Some for profits / physician owned is all that is left
We need to maintain these relationships or they will go elsewhere for IGT Possible cheaper sources This provides more net dollars than UC & DSH to many rural hospitals Private capacity is now the commodity, not IGT This will increase, now with the UCC limitations!
HHSC has implemented a new UPL program for Non-state government-owned nursing facilities (NF). RULE 355.314 Supplemental Payments to Non-State Government-Owned Nursing Facilities adopted September 1, 2012 and revised effective January 1, 2014, 38 TexReg 9243
Federal Participation Title 42 CFR 447.272 allows states to claim federal matching funds under Medicaid up to what Medicare would pay for a similar service Medicare SNF RUG rates Based on first payments this was a 57% to 75% net gain (after IGT) Under this UPL the state share comes in the form of Inter-Governmental Transfers (IGTs) from local government owned entities
To participate, a governmental entity other than the State of Texas MUST: Hold the license and be party to the facility s Medicaid contract and be one of the following: County City Hospital District or Hospital Authority Healthcare District
Eligible Participants: Prior to October 1, 2013, there were 25 Non-State Public Nursing Facilities who were eligible for these payments. A couple of these homes have not participated In addition, there have been approximately 9 nursing home change ownership to be eligible for participation. There are approximately 15-20 planned CHOWs for the 3rd quarter to participate. (Per DADS)
Payments to Eligible Participants: The first payments are this month Approximately $17.7 million to the 32 nursing homes for the first 2 quarters; $12.9M was the original 25 homes Approximately $7.3 million in IGT requirement (41.31% state share) for this payment; The potential aggregate cap for all nursing homes $3.1 billion The previous 25 Non-State Public Nursing Facilities attributing $25.9M of the $3.1B. Rural Home (conservative estimate) $651M Larger than all other rural programs.
There are approximately 1,200 nursing homes in Texas; To be eligible to participate, the CHOW must be effective on or before:
NH UPL and Managed Care Impacts: SB 7 directed HHSC to implement Managed Care for Long Term Care HHSC has delayed the implementation to March 2015 HHSC has committed to continuing the program after managed care implementation Various proposals for a viable solution or alternative reimbursement methodology that will allow the continuation of UPL-like payments in your Managed Care Medicaid payments Meeting next Monday with HHSC
Medicaid is basically all dependent with the correct coding. Verify & Improve No longer cost based = Cut cost Waiver Renewal is very vital for Texas Assist in developing RURAL ideas for the renewal Small Anchors At Risk Keep this a locally driven program For example, if RHP 11 & 19 was merged with 10, would the rural providers get a fair deal from Ft. Worth? From Austin? DSRIP Make your projects work! Meet metrics & keep great data to support the projects outcomes
DSH Maximize your DSH / UCC tool The HSL is the important part, but all of it can be important as the rules are still not final The allocations within the pool are currently based on full UCC UCC Consider becoming a private hospital There are distinct advantages, as the pool may be larger
Private programs Maximize burden alleviation Be reasonable with privates They are spending millions, and the delays are compounded for them NH UPL Needs legislative support Look at local homes Examine opportunity with chains and other homes
Questions