2013-14 Executive Budget with 30-Day Changes

MEDICAID Proposals
Investments / (Savings)

($ in Millions)

  • Matrix is also available in Excel Format (XSL, 133KB)
No. Initiative Staff Effective Date Art VII 2013-2014 Impact 2014-2015 Impact Description
Yes/No Gross State Gross State
Affordable Housing
  Supportive Housing (related to Nursing Home and Hospital Closures) Liz M., Mark K. April 2013 No $0.00 $0.00 $0.00 $0.00 Funding is generated from Medicaid savings ($3.85 million state) associated with the closure of two nursing homes and two hospitals, and the decertification of nursing home and hospital beds, effective April 1, 2012. Funding will be used for MRT supportive housing initiatives.
Totals $0.00 $0.00 $0.00 $0.00  
Basic Benefit Review
  Lumbar Discography Greg A. October 2013 No ($0.05) ($0.03) ($0.11) ($0.06) Discography is a diagnostic procedure used to determine if the lumbar disc is the source of low back pain and results may put patients at risk for undergoing surgery. Pursuant to the recommendation of the MRT Basic Benefit Review Work Group, coverage of lumbar discography for chronic low back pain will be discontinued due to the lack of medical evidence and the potential for patient harm.
  Transcutaneous Nerve Stimulation (TENS) for the Treatment of Pain Greg A. October 2013 No ($1.26) ($0.63) ($2.52) ($1.26) TENS is commonly prescribed for pain treatment. Pursuant to the recommendation of the MRT Basic Benefit Review Work Group, Medicaid will limit coverage of TENS to pain associated with knee osteoarthritis. there is a lack of evidence to support the efficacy of TENS for such use other than osteoarthritis of the knee.
  Implantable Infusion Pumps for Non-Cancer Pain Greg A. October 2013 No ($0.14) ($0.07) ($0.27) ($0.14) Infusion pumps are surgically implanted to provide round-the-clock drug therapy for pain management for chronic non-cancer pain ( e.g., arthritis, low back pain, etc.). Pursuant to the recommendation of the MRT Basic Benefit Review Work Group, coverage for implantable infusion pumps, except in cases of intractable cancer pain, will be discontinued due to insufficient evidence and the potential for patient harm. Serious drug and device related adverse events, including death may occur with infusion pumps.
Totals ($1.45) ($0.73) ($2.90) ($1.46)  
Payment Reform & Quality Measurement
  Develop Price for Specialty Nursing Homes April 2013 Yes   $0.00 $0.00 $5.00 $2.50 Develop Price for Specialty Nursing Homes Facilities - Includes Implementing Price for Pediatric Facilities and Blythedale/CRC Rate Methodology per Recommendations of Medicially Fragile Children Report.
  Essential Community Provider Network and Vital Access Providers John U. April 2013 No $52.00 $26.00 $24.00 $12.00 The Essential Community Provider Network (short-term funding) and Vital Access Providers (ongoing rate enhancement or other support) ensure access to care for patients. New York State will assume an active role in ensuring certain essential community providers (hospitals, nursing homes, D&TCs or home health providers) will be eligible to receive short-term funding to achieve defined operational goals such as a facility closure, merger, integration or reconfiguration of services. this proposal will increase the total VAP/Safety Net pool to $182 million in 2013-14 and $153 million in FY 2014.
  Reallocate $30M from the NH Financially Disadvantaged Program to the VAP/Safety Net Program for Nursing Homes John U. April 2013 Yes $0.00 $0.00 $0.00 $0.00 this proposal eliminates the statutory authorization for the $30 million Financially Disadvantaged Program for nursing homes to effectuate the reallocation of these resources to nursing home providers under the VAP/Safety Net Program.
Totals $52.00 $26.00 $29.00 $14.50  
Additional Considerations
  Indigent Care Pool Reform/Voluntary UPL Payment John U. April 2013 Yes $25.00 $12.50 $25.00 $12.50 Bring ICP methodology into compliance with Federal DSH requirements by basing methodology on Medicaid and uninsured loses and excluding bad debt.
  Reduce APG Investment for Hospital Outpatient Payments John U. April 2013 Yes ($25.00) ($12.50) ($25.00) ($12.50) Revise statutory language to reflect reduction to APG investment reflected in prior year appropriation language.
  Reinvest Savings Related to the Elimination of Trend Factor for Certain Providers John U. April 2013 Yes $0.00 $0.00 $0.00 $0.00 the savings attributable to the elimination of the trend factor for 1) foster care will be reinvested in a pay performance/quality pool and 2) pediatric nursing homes will be reinvested to smooth the transition to a new price, which will serve as benchmark rate for the transition to Managed Care.
  Minimum Supplemental Rebates Greg A. October 2013 Yes ($0.90) ($0.45) ($1.78) ($0.89) Require manufacturers of brand drugs that are eligible for State public health plan reimbursement to provide a minimum level supplemental rebate to the State. If a rebate is not provided by the manufacturer, prior authorization may be required.
  Eliminate Prescriber Prevails for Atypical Antipsychotic Drug Class (MCOs) Greg A. July 2013 Yes ($18.75) ($9.38) ($25.00) ($12.50) DOH is required to approve a prescriber's request for prior authorization of a prescription drug regardless of whether clinical criteria has been met. this proposal would eliminate the prescriber prevails provision and supports Federal regulations that prohibit payment for experimental, investigational or unproven medical treatment.
  Eliminate Prescriber Prevails for All Classes of Drugs (FFS) Greg A. July 2013 Yes ($2.07) ($1.04) ($2.70) ($1.35) this proposal is consistent with the above proposal and eliminates the prescriber prevails provision for Medicaid FFS for all classes of drugs.
  Eliminate Prescriber Prevails for Opioids in Excess of Four Prescriptions in a 30 Day Period Greg A. July 2013 Yes ($0.03) ($0.02) ($0.04) ($0.02) this proposal will allow the Department to deny prior authorization for opioid analgesic prescriptions in excess of 4 prescriptions in a 30 day period, when clinical criteria as established by FDA and manufacturer guidelines, official compendia, the Medicaid Drug Utilization Review Board (DURB) and the Pharmacy & therapeutics Committee (P&TC) are not met.
  Reduce FFS Pharmacy Reimbursement Rate to AWP Minus 17.6% Greg A. July 2013 Yes ($3.60) ($1.80) ($4.80) ($2.40) this proposal reduces FFS pharmacy brand reimbursement rate from Average Wholesale Price (AWP) minus 17% to AWP minus 17.6% which reflects the rate achieved by the managed care plans.
  Eliminate Summary Posting Requirement for P&TC Meetings Greg A. April 2013 Yes ($0.36) ($0.18) ($0.28) ($0.14) this will eliminate the requirement to provide a written P&TC summary notice and allow electronic meeting recordings to serve as public notice. this will enable the Department to implement changes to the Preferred Drug List (PDL) more efficiently, and expedite the earning of supplemental rebates.
  Tighten Early Fill Edit Greg A. July 2013 Yes ($0.80) ($0.40) ($1.06) ($0.53) Currently, beneficiaries are able to obtain up to an extra 90-day supply of medications over the course of 360 days. this proposal would tighten the FFS pharmacy early fill edit to ensure ample supply and reduce waste so that prescriptions can only be refilled when the amount of medication on hand is equal to or less than a 7-day supply.
  Incontinence Supply Contractor Jonathan B. April 2013 Yes ($2.50) ($1.25) ($5.00) ($2.50) Authority to contract for management and provision of incontinence supplies using existing provider network. Savings realized from reduction in per unit cost obtained through leveraging Medicaid's bulk purchasing power, potentially combined with purchasing for State and county-run inpatient and residential facilities. Estimate is preliminary based on survey of other State Medicaid efforts and previous contract pricing for State facilities.
  Hearing Aid Administrative Streamlining Jonathan B. October 2013 No ($0.25) ($0.13) ($0.50) ($0.25) DOH to propose regulation change to facilitate transition from paper to electronic billing to reduce administrative burden on providers and the State. For the 24 types of hearing aids currently covered, DOH will seek industry and stakeholder input on development of maximum fees based on an average cost of products representative of each type of hearing aid. this will allow automated processing of claims and is consistent with current regulations and procedures for complex wheelchairs and other equipment as well as other payors nationwide.
  Medicaid Early Intervention Restructuring Greg A. April 2013 Yes ($1.43) ($0.48) ($5.70) ($1.90) Integrating covered EI services into the Managed Care program; using supplemental evaluations to established re-referred EI children; require screening of children referred to EI with a diagnosis; using medical and other records to establish eligibility for EI.
  Gold STAMP Program to Reduce Pressure Ulcers Jackie P. April 2013 No $0.50 $0.50 $0.00 $0.00 these funds will be used to extend the Gold STAMP efforts through 2013 by establishing 4 additional collaboratives in those areas of the State that have not yet been targeted or are underserved. Funds will also be used to enhance marketing of the initiatives Statewide and to perform an evaluation to determine the effectiveness of the Gold STAMP model on poor performing providers.
  ALP Targeted Expansion and Debt Service Mark K. April 2013 Yes $0.00 $0.00 $0.00 $0.00 Provides for up to 4,350 additional ALP beds for "transitional " adult homes through an RFP process. Allows for limited capital reimbursement for these new beds pursuant to Commissioner regulations.
  Balance Incentive Program Implementation Mark K. April 2013 No $20.00 $10.00 $0.00 $0.00 BIP is a provision of the Affordable Care Act to provide enhanced long term services which will allow NYS an opportunity to receive significant enhanced FMAP over the duration of the grant.
  Spousal Support   April 2013 Yes ($68.60) ($34.30) ($137.00) ($68.50) State Social Services law is amended to conform with Federal law with regard to spousal contributions and responsibilities for spouses residing together in the community. this amendment, which has been proposed in the past, will eliminate the ability of non applying spouses to refuse to contribute toward the cost of care for the applicant spouse.
  2012-13 Global Cap Underspending John U. April 2013 No TBD ($200.00) $0.00 $0.00 Use 2012-13 Global Cap underspending to pre-pay 2013-14 expenses.
  Restore 2% Across the Board Reduction John U. April 2013 Yes $40.00 $20.00 $714.00 $357.00 Restoration begins in the forth quarter of SFY 2013-14.
Totals ($38.79) ($218.92) ($530.14 $266.02  
Revenue Maximization Initiatives
  Federal Revenue from Additional Emergency Medicaid Claiming and Other Possible Efforts Greg A. April 2013 No $0.00 ($250.00) $0.00 ($85.00) Aliessa populations claimed as FNP except for emergency services. However, none of the emergency services provided to Aliessa individuals in a managed care setting are claimed as FP. this project will identify and submit these services to FP.
Totals $0.00 ($250.00) $0.00 ($85.00)  
Accelerate MRT
  PCMH Savings Greg A. April 2013 No ($13.70) ($6.85) ($6.85) ($3.43) Eliminate payments for 2008 PCMH recognized Level 2 providers and reduce payments from $6 pmpm to $5 pmpm for 2008 PCMH recognized Level 3 providers. Assumes that some providers will meet 2011 standards to receive incentive payment.
  FIDA Savings from Community DUALS/Administration John U. January 2014 No ($13.00) ($6.50) ($55.00) ($27.50) Additional savings associated with enrolling up to 122,000 dual eligible (Medicare/Medicaid) recipients in the FIDA demonstration.
  Stricter Utilization Management by Transportation Manager Greg A. March 2013 No ($12.10) ($6.05) ($12.10) ($6.05) NYC transportation manager will accelerate migration to livery and public transportation at the most appropriate mode of transport. Improved transportation utilization patterns will be implemented for lower performing providers.
  Accelerate MLTC Enrollment John U. April 2013 No ($6.50) ($3.25) ($2.50) ($1.25) Accelerate mandatory enrollment from 2,000 enrollees per month to 4,000 enrollees per month. NYC Mandatory enrollment expected to generate -1.3% savings from FFS spend. Saving estimates are offset by $450,000 for implementation costs.
  Implement Appropriateness Edits on Emergency Medicaid Pharmacy Claims Greg A. April 2013 No ($3.60) ($1.80) ($3.60) ($1.80) Implement an edit which will eliminate inappropriate emergency Medicaid pharmacy claims provided to individuals who are eligible for emergency services only (estimated savings are net of OBRA drug rebates).
  Accelerate BHO/IMD Greg A. April 2014 Language included 2013-14 Executive Budget $0.00 $0.00 ($24.00) ($12.00) DOH and OMH are exploring options to generate savings which includes converting State-only funding (i.e., supportive housing/State psych inpatient) into Medicaid capitation payments with shift to BHO/HARPS.
Total ($48.90) ($24.45) ($104.05) ($52.03)  
Other Reforms/Savings
  Managed Care Efficiency Adjustments Pat R. July 2013 No ($50.00) ($25.00) ($50.00) ($25.00) DOH is working with Mercer/3M to identify higher and lower performing health plans on savings aimed at reducing hospital readmissions, emergency department use and other avoidable health care costs.
  Reduce Accounts Receivable Balances John U. April 2013 No ($50.00) ($50.00) ($68.00) ($79.48) DOH will work with provider groups to develop a plan to reduce liabilities owed to the State.
  Activating Ordering/Prescribing/Referring/Attending Edits Jonathan B. October 2013 No ($8.50) ($4.25) ($17.00) ($8.50) Savings identified through implementation of ACA requirement that ordering/referring practitioners must be enrolled in Medicaid program for fee-for-service claims payment to be made. Estimate assumes six month transition from April to October 2013 to utilize the new expedited enrollment process and 90% improvement in compliance over current levels.
  Increase Manual Review of Claims Jonathan B. July 2013 No ($16.50) ($8.25) ($22.02) ($11.01) Improved editing allows better targeting of potential billing errors, fraud, waste and abuse through additional cost effective manual review in fee-for-service, including provider on review, near duplicate, third party zero fill, timely billing, and potential inappropriate combinations of services.
  Basic Benefit Enhancements Greg A. October 2013 No ($10.00) ($5.00) ($20.00) ($10.00) Discontinue coverage for Functional Electrical Stimulators (FES) for Spinal Cord and Head Injury, Cerebral Palsy, and Upper Motor Neuron Disease.
  Gold STAMP Program to Reduce Pressure Ulcers Jackie P. April 2013 No ($6.00) ($6.00) ($8.00) ($8.00) Additional Medicaid savings from expanding efforts to reduce pressure ulcers for NH residents.
  Eliminate e-Prescribing Incentive Greg A. July 2013 No ($2.08) ($1.04) ($3.10) ($1.55) To encourage the use of e-prescribing, the NY State legislature authorized the payment of an incentive to eligible providers for each approved ambulatory Medicaid e-prescription plus a maximum of five refills. this proposal will eliminate the e-prescribing incentive payment as it will no longer be required due to sufficient federal incentives, and the State requirement (I-STOP) for providers to adopt e-prescribing in 2014.
Total ($143.08) ($99.54) ($188.12) ($143.54)  
Federal Health Care Reform
  Federal Health Care Reform Judy A. January 2014   $0.00 ($163.00) $0.00 ($520.00) Additional Federal Financial Participation becomes available for childless adults in January 2014.
  Repeal Family Health Plus Judy A. January 2014 Yes $0.00 $0.00 ($106.00) ($38.50) the ACA establishes a new mandatory coverage group for adults to 138% of FPL. As such, all FHP enrollees will be subsumed into the new Medicaid eligibility category. the adults with incomes between 138% of FPL and 150% will be able to enroll in a QHP with a tax credit. the State will wrap the QHP co-premium and cost-sharing for those who were previously enrolled in FHP. there is no longer a need for the current FHP program.
  Define the Medicaid Benchmark Plan as the Current Medicaid Benefit (without Nursing Home Care) Judy A. January 2014 No $0.00 $0.00 $307.00 $115.13 the ACA requires states to enroll the new adult eligibility group into a benchmark plan. the benchmark plan can be the state's Medicaid benefit or it can be one of four other benchmark options. 1.1 million adults subject to the benchmark benefit are already enrolled in Medicaid or FHP and of those 60% are enrolled in Medicaid. Choosing the Medicaid benefit would be the least disruptive to current enrollees, easier to administer, preserves continuity of coverage as income fluctuates, and eliminates the need to separately identify persons with disabilities or other special health needs who cannot be mandated into a lesser benefit than the full Medicaid benefit and move them into another eligibility category.
Totals $     - ($163.00) $201.00 ($443.38)  
Grand Totals ($180.22) ($730.64) $465.07 ($444.88)