Situation Report | March 29, 2021
The state Department of Health (DOH) has posted providers’ direct care medical services component of Fiscal Intermediary (FI) rates and more information about the change to a per member per month (PMPM) reimbursement for FI administrative expenses.
The direct care portion of FI rates is here and the FI PMPM guidance is here.
As previously communicated to members, effective April 1, 2021, DOH will implement a three-tier PMPM rate structure for reimbursement of the administrative services component for FI services provided to Medicaid recipients enrolled in the Consumer Directed Personal Assistance Program (CDPAP). The CDPAP administrative claim must be submitted on or after the first day of the month immediately following the month for which reimbursement is being claimed.
The three tiers will be based on the number of direct care hours authorized per member per month. The tiers are:
- Tier 1 (1 to 159 direct care hours authorized per month) — a monthly FI PMPM rate per consumer of $145.
- Tier 2 (160 to 479 direct care hours authorized per month) — a monthly FI PMPM rate per consumer of $384.
- Tier 3 (480 hours in direct care hours or above authorized per month) — a monthly FI PMPM rate per consumer of $1,036
FIs will bill a separate administrative rate code (below) for each approved/authorized consumer once per each month that the FI is providing service to that consumer based on the greatest number of direct care hours authorized in that month by the Local Department of Social Services (LDSS).
The rate structure and billing codes for administrative reimbursement will be active in eMedNY this week and will be as follows:
- Tier 1 — Rate code 8400
- Tier 2 — Rate code 8401
- Tier 3 — Rate code 8402
The provider-specific direct care medical services component of the rate has been modified to remove the FI administrative costs consistent with the changes above. Providers are advised to continue to utilize current provider-specific CDPAP rate codes for the direct care medical services component as they have in the past.
Additional past guidance is here for LDSS and here for Managed Long Term Care plans.
Contact PersonalCare-Rates@health.ny.gov for questions on the rates or ConsumerDirected@health.ny.gov for questions on the policy.