Ohio Medicaid Update Key Policies Affecting Payment to Skilled Nursing Centers Diane J Dietz Assistant Executive Director, OHCA Financial Eligibility Determinations Problems persist post Ohio Benefits/9401 conversion OHCA continues to push for improvements ODM now monitoring county progress Minor improvements/delays greatest in urban counties Lorain County strike National attention seen recently Member input needed Leadership considering next steps 1
Financial Eligibility Redeterminations Ohio Benefits tightens redetermination process Runs auto discontinuance closures first week of renewal month Caseworkers must mark packet received to prevent auto closures Providers who wait could run risk of eligibility terminating; reinstatements could cause payment gaps QIT redeterminations require documentation of monthly transactions Post Eligibility Treatment of Income Policy Changes Changes to 5160:1-6-07; took effect 9/1/2017 Section (6)(b)(ii) Expenses for [medical care] that were incurred while serving in a RMCP shall not be counted as unpaid past medical expenses and shall not be subtracted from PL calculation Practice of collecting resources only during RMCP, and collecting room and board following as unpaid past medical, no longer an option Appeal provisions for extreme hardship in 5160:1-6-06.5 ; available only when RMCP is set 2
New Functional Eligibility Policy New process underway due to Ohio s participation in BIP and desire to collect better data on individuals served New process will be required No alternative process accepted Separate process for children & adults Will be automated no more faxes to PAA Currently delayed due to system issues Launching soon in HENS (location of PASRR) New NF LOC Rules & Instrument Criteria remains the same; process changes New Adult LOC Questionnaire (ODM 10127) Replaces paper 3697 or alternative process ADL person centered questions whereby algorithm will be used to calculate level of need what will the results be? If cognitive criteria only trigger, in-person assessment using BCAT to render determinations how will this affect individuals with mental health needs? 3
Other Unknown Issues with ODM 10127 New form is more extensive; staff resources Demographic and payor information plus diagnosis, medications, skilled nursing & rehab services including frequency Current draft rule says ODM 10127 must to be completed by RN, LISW, LSW OHCA opposes this; supporting documentation (MDS etc.) still required ADL & IADL will be assessed using person centered questions Will all sections need complete? New LOC Policy & Managed Medicaid Current initiative underway to ensure Medicaid Managed Care Plans are following appropriate LOC criteria and also issue appropriate appeal rights to beneficiaries Also discussing disenrollment responsibilities Also discussing discharge responsibilities Opportunity to advocate for: Returning Functional Eligibility Functions to PAA 4
Program Integrity: NF Audits Still waiting on SFY 2013 audit reports Improvements discussed may include: 2014 will be combined Goal of auditing multiple years going forward Auditor consistency within company/over years Internal data source improvement CHOPS setting framework for PL issues due to elimination of 9401s and various MITS errors Audits related to PA1 & PA2 payments remain in process outlining phase Exception Reviews Proposal to conduct ERs retrospectively under a new set of guidelines produced by Myers & Stauffer was met with strong opposition from OHCA Process outlined did not comport with existing rule; unlawful to apply rules that have not been adopted; SDR manual fraught with issues ODM suspended activity Now rewriting rules; say they plan to conduct targeted reviews under existing rules soon. 5
Alternative Purchasing: Medicaid Vent Program Budget language reducing payments to 34% of average LTACH rate has not been pursued ODM NF Policy Administrator says program was created using alternative payment method permitted by statute (includes the VAP outcome) Possible retrospective payment increase to July 1, 2017 DOS claims Coding ES2 or ES3--will there be an audit one day similar to PA1 and PA2 audits? Weaning program component discussed being added to current program Thank You!! Questions can be directed to: Diane Dietz Assistant Executive Director OHCA ddietz@ohca.org; 614-540-1334 6