Questions and Answers

Pricing Methodology

Question Number Question Answer
1 What is the standard rate? The base price (representing a case mix of 1.00) under the episodic payment model is $5,633.
2 What are the case mix weights? The case mix weights are listed under EPS - Base Price, Resource Groups, Case Mix Indices, Outlier Thresholds, Rate Codes
3 What are the CBSA or similar adjustments to the standard rate? The base price will be adjusted by a Wage Index Factor which uses 10 Labor Market Regions as determined by New York State Department of Labor. Preliminary wage factors will be released for the testing phase (begins Jan. 4, 2012) and final factors will be determined prior to April 1, 2012.
4 Will the Wage Index be the same as Medicare and will it be effective on the same dates? The Wage Index Factor will be used to equalize labor price differences within the state. Since the payment system is based on NYS expenditure data, the Medicare wage factors, based on differences in national labor markets would not be applicable. Changes to the index values may not occur at the same time as Medicare revisions.
5 Will the wage index be based on the county where the service is performed, patient's home, or the county where the agency is licensed? The applicable wage index will be based on the Locator Code for the billing agency
6 Regarding the HHA volumes in the weighted calculations for the overall wage index per region, were those in visits or hours? Weighting was based on reported visits.
7 Is there a labor and non-labor portion of the visits and episodes? Yes. The labor percentage applicable to the Wage Index adjustment component of the payment methodology is 77%.
8 Will a LUPA be identified as an episode with 4 or fewer visits, similar to Medicare LUPA identification? No, the Low Utilization Payment Amount (LUPA) threshold is $500 as determined using statewide weighted average rates.
9 What are the LUPA rates ? Rates to determine the underlying cost of services for both LUPA and outlier calculations will be based on the statewide weighted average of the most current fee-for service rates at the time of 5/1/12 implementation.
10 Is there an outlier calculation for high utilization cases? If so what is the outlier loss sharing rate? Yes, there is an outlier payment determination, which is set at 50% loss sharing.
11 Is there a LUPA add-on for SOC episodes? No.
12 Will the number of therapy services be factored into the calculation? No.
13 Does the dollar figure change based on early/late billing episodes? The case mix adjustment to the price (as determined by the Medicaid grouper) varies depending on whether the OASIS assessment is a Start of Care assessment or a Recertification (see the 108 case mix groups).
14 Is the final episodic price based on the initial OASIS or the ending OASIS? Final payment will be based on the billed Rate Code, which should correspond to the most recent OASIS completed on or before the start date of the episode.
15 When the episode is an Outlier PEP, do we have to recalculate case mix's outlier threshold amount? That is, do we have to see that the episode is a PEP first, get the number of days and then prorate the outlier threshold to those days before comparing costs to outlier threshold? The outlier threshold will not be prorated for partial episodes. The total payment amount for a full 60-day episode, including any outlier component, will first be computed; then the total will be prorated if the episode is less than 60 days and does not qualify for one of the exceptions to partial payment adjustments.
16 Agencies are allowed to complete an OASIS RFA-03 when the patient returns from a hospital stay within the last five days of the previous episode to calculate the EEP for the next episode. Is your intention to keep this logic? Or, are you stating that the calculation will be based on the RFA completed regardless of Initial episode or Subsequent episode? The billed rate code must be consistent with the most recent OASIS assessment on or before the first day of the billed episode. If a provider completes a new assessment five days before the end of a Medicaid episode, the new assessment will determine the rate code to be used for the next Medicaid episode.
17 With the release of the 2012 Initial Rates for CHHAs we have received some questions as to how providers will be expected to handle (deal with) the workforce add-on monies (3% and 4.7% RT&R) monies with the implementation of Medicaid EPS 5/1/12? Will you be issuing further instructions on this. The recruitment and retention funding, as well as the provider requirements on use of the funding, remain in effect in accordance with current statute ( PHL 3614.8 and 9-10 ) through March 31, 2014. The Medicaid episodic methodology payment prices have been determined to include the full amount of the statutorily authorized funding for CHHA's. Under Medicaid episodic payment agencies will continue to be required to properly provide such funding to direct care workers and to continue to account for the funding in accordance with requirements detailed in the above - noted statutory provisions.
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