OKLAHOMA S UPPER PAYMENT LIMIT (UPL) PROGRAM TRAINING GUIDE April 2017
2 Disclaimer The information provided is current as of April 2017 and is subject to change. Stay current with up-to-date information on the OHCA public website: www.okhca.org
3 UPL Authority The Social Security Act section 42 CFR 433.50,52,54,57,66 and 67 allows for Federal Supplemental Payment of UPL provisions. Pending State Plan Amendment
4 UPL Basics Non-State Government Owned (NSGO) nursing facilities who elect to participate The NSGO receives a quarterly supplemental payment that increases the Medicaid Rate to the Average Medicare Equivalent Rate increasing the overall rate for facilities to promote quality care of nursing home members Government owned status permits the NSGO to make an intergovernmental transfer (IGT) to the Oklahoma Health Care Authority to pay the non-federal share of the supplemental payment
5 Program Requirements NSGO Requirements: Execute an Agreement of Participation with OHCA 30 days prior to the quarter of participation with annual renewal New NSGO participants may only enter the UPL program at the start of each quarter
6 Program Requirements Continued Licensed as a Skilled Nursing Home provider Operating license held by NSGO Nursing Facility Requirements: Active Focus on Excellence (FOE) participant Meet at least 2 of 5 care criteria UPL Program Eligibility Attestation submitted to OHCA 30 days prior to the quarter of participation with annual renewal
Must be submitted 30 days prior to the anticipated quarter of participation with annual renewal 7
8 Program Requirements Continued Agreement of Participation and Attestation of Eligibility Submission Dates (with annual renewal) Quarter of Participation SFY Must be submitted by: 1st Qtr (July-Sept.) May 31 2nd Qtr (Oct.-Dec.) September 1 3rd Qtr (Jan.-March) December 1 4th Qtr (April-June) March 1 *If any of these dates fall on a Saturday or Sunday, the due date will be close of business Monday.
Funding Flow 9 The supplemental payment will be calculated by taking the estimated Medicare Equivalent Rate Adjustments for coverage differences Facility specific Medicaid rate 5 Care Criteria = 100% of payment 4 Care Criteria = 95% of payment 2 Care Criteria = 85% of payment 3 Care Criteria = 90% of payment
Funding Flow 10 A Provider Participation fee will be assessed on each participating Nursing Facility in the UPL program, in the form of a Per Patient Per Medicaid Day (PPMD) calculation, to be phased in over a 3 year period: Year 1: $6.50 PPMD Year 2: $7.50 PPMD Year 3: $8.50 PPMD, or the equivalent of 10% of Nursing Home Medicaid Budget, whichever is less
11 Agreement of Participation These questions require that supporting documentation be attached, supporting documentation may include, but is not limited to: any copies of rules or statutes referenced in your summary audited financial statements operating license disclosure of ownership management agreement With annual renewal lease or sub-lease Certificate of Amendment authorizing the NSGO to operate the nursing facility under its name
Agreement of Participation Cont. 12 1. Is the health care facility owned or directly operated by a unit of government within the state? For purposes of your response to this question, "owned or directly operated by a unit of government" means that this unit of government is the holder of the license issued by the Oklahoma State Department of Health to operate this facility as a nursing facility. YES / NO If yes, what unit of government owns or directly operates the facility? [ ] State [ ] City [ [ County [ ] Other Governmental Unit (Specify) *Please attach supporting documentation, including citation to any applicable statutory or regulatory authority.
13 Agreement of Participation Cont. 2. Provide an attachment that describes in detail the governing structure of the health care facility. 3. Does the unit of government that operates the health care facility appropriate funding to the health care provider? YES / NO If no, please explain how the health care facility is funded and what role, if any, the unit of government plays in providing that funding. Please attach supporting documentation *Please attach supporting documentation, including citation to any applicable statutory or regulatory authority.
14 Agreement of Participation Cont. 4. Does the government unit have an obligation to fund the health care facility s: Expenses? YES / NO Liabilities? YES / NO Deficits? YES / NO *Please attach supporting documentation, including citation to any applicable statutory or regulatory authority.
15 Agreement of Participation Cont. YES / NO 5. Does the government unit have legal liability for the operation of the health facility? If yes, please provide the written summary of the unit of government s legal liability to the facility *Please attach supporting documentation, including citation to any applicable statutory or regulatory authority.
16 Agreement of Participation Cont. YES / NO 6. Does the facility have the ability to make intergovernmental transfers to the state either directly or through the unit of government? If yes, please explain the rationale that supports your response *Please attach supporting documentation, including citation to any applicable statutory or regulatory authority.
17 CARE CRITERIA REQUIREMENTS
18 5 Care Criteria Reduction in Return to Acute (RTA) Care Participate in Oklahoma Healthy Aging Initiative Satisfaction Survey Pneumonia and Flu Vaccination Initiative Five-Star Quality Measures *All UPL forms must be submitted by the 5th business day after the quarter ends with supporting documentation
19 Care Criteria: Reduction of Return to Acute (RTA) Care Quarter 1 & 2 (6 months) Written plan for reduction of RTA Identify baseline-cy 16 Identify root cause analysis Mgmt & Communication tool Advance directive planning Training needs Goal Timeline Quarter 2 or 3 Implement plan Submit progress improvement report & goals Submit baseline
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21 Care Criteria: Healthy Aging Initiative Quarter 1 Oklahoma Healthy Aging Pledge prevent and reduce falls improve nutrition increase physical activity reduce depression Written plan (one area of improvement) Identify baseline Timeline
22 https://www.ok.gov/health/protective_health/quality_improvement_and_evaluation_service/healthy_agin g:_living_longer_better/
Care Criteria: Healthy Aging Initiative 23 Quarter 2 Implement plan Identify baseline Quarter 3-Ongoing Compliance Progress improvement report & goals Identify baseline
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Care Criteria: Satisfaction Survey 25 Quarter 1 Satisfaction survey (approved by UPL Quality Team) Identify one area of improvement Identify baseline Written plan Timeline Quarter 2 Implement plan Identify baseline Quarter 3-Ongoing Compliance Progress improvement report & goals
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27 Care Criteria: Pneumonia & Flu Vaccination Initiative Quarter 1 Written plan Identify baseline Measure code 411 and resident census (CY16) for the Flu vaccination program Measure code 415 and resident census (CY 16) for the Pneumonia vaccination program Timeline Quarter 2 Implement plan Identify baseline Quarter 3- Ongoing Compliance Submit progress improvement report and goals
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29 Care Criteria: Five-Star Quality Measures Quarter 1 Current overall rating from CMS Nursing Home Compare site Quarter 2 Prior quarter & current quarter from the CMS Nursing Home Compare site Quarter 3-Ongoing compliance Maintain an overall rating of 3 or better or improvement
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31 Care Criteria Summary Within 5 business days after the quarter end, nursing facility submits completed care criteria forms to OHCA (on a quarterly basis) LTCQualityAssurance@okhca.org All facilities must provide supporting documentation (baseline, written plan, progress improvement report, data sources) for all care criterions
32 Things to Come State Plan Amendment Approval UPL Calculation Future Training Myers & Stauffer Portal FOE & QOC Portal https://foe.okhca.org456/foeqocexternalportal/
33 www.okhca.org
34 UPL Program Contacts Long-Term Care Quality Assurance Phone: (888) 287-2443 E-mail: LTCQualityAssurance@okhca.org UPL Provider Website http://okhca.org/providers.aspx?id=19987 Susan Geyer UPL Program Manager 405-522-7199 Susan.Geyer@okhca.org Jennifer Wynn Quality Assurance Program Coordinator 405-522-7306 Jennifer.Wynn@okhca.org Irene Perez Quality Senior Research Analyst 405-522-7739 Irene.Perez@okhca.org Eboni Bolds Quality Senior Research Analyst 405-522-7847 Eboni.Bolds@okhca.org
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