Situation Report | March 15, 2021
On March 11, the state Department of Health (DOH) posted two guidances — one for local departments of social services (LDSS) and one for Managed Long Term Care plans — about reimbursing Fiscal Intermediaries (FIs) for their administrative services through a “per member per month” (PMPM) structure starting April 1.
The PMPM change was implemented in a final rule posted on January 13.
While both guidances are identical, they note that:
Medicaid managed care plans may, but not are not required to, reimburse FIs using the tiered administrative PMPM rate structure set forth above. Alternatively, Managed Care Organizations (MCOs) may negotiate administrative rates using a PMPM or an alternative structure with FIs pursuant to their contracts. In either case, MCOs must continue to make timely reimbursement to FIs for the direct wage costs of personal assistants including ensuring that contractual reimbursement meet NYS minimum wage and wage parity requirements. MCO capitation rates paid by the DOH will be adjusted, subject to actuarial soundness certification by the independent actuary, to reflect the change in Medicaid FFS reimbursement policy.
DOH stresses that the policy guidance does not impact wages or wage-related requirements for CDPAP personal assistants, including state law or regulatory requirements related to minimum wage, overtime pay, or wage parity, where applicable.
This guidance also does not impact the requirements of the FI to bill Medicaid fee-for-service (FFS) the approved hourly rate for direct care services, DOH says. The Department will reduce the current hourly CDPAP rates to exclude the FI administrative costs included in the FI PMPM. The following non-direct care service costs will continue to be included within the direct care hourly FFS rates and are not included in the FI PMPM:
- Capital costs.
- Up to 2 percent allowance for profit or reserves.
- Workforce recruitment and retention supplements.
- Minimum wage supplements.
For claiming reimbursement for Medicaid FFS cases, FIs must submit a claim for their FI PMPM each month through the standard eMedNY billing process using the codes in the guidance. Those codes are based on the greatest number of authorized direct care hours of consumer directed personal assistant services during the month for which the FI PMPM is being claimed and the monthly hours determined under each consumer’s utilization tier.
FIs will submit FI PMPM claims no earlier than the first day of the month immediately following the month of services and no later than the timeframes set forth in 18 NYCRR Section 540.6. Therefore, FIs should start billing under this new methodology on or after May 1, 2021 for FI administrative services performed on or after April 1, 2021.
Questions related to the guidance documents should be sent to firstname.lastname@example.org; questions related to a fiscal intermediary’s specific rates may be sent to email@example.com.