Value Based Purchasing – CMS Issues Request for Additional Information

On August 14, 2013, CMS issued a Request for Additional Information to the Indiana Medicaid Office concerning the State Plan Amendment (SPA) to implement the Value Based Purchasing (VBP) program. Click here to read the CMS letter.  The VBP program is the new methodology for an add-on to the Medicaid NF rate that is based on Report Card Scores, nursing hours per resident day, and staff retention and turnover. Click here for details on the VBP program.  In the CMS letter, the agency suggested to Indiana Medicaid that the VBP program incorporate certain MDS Quality Measures, even though those Quality Measures were not part of the original submission.  CMS also requested that additional detail be added to the SPA concerning calculation of the various VBP domains. 

Indiana Medicaid responded to the CMS letter on September 9th. Click here to read Indiana Medicaid’s response.  With the submission on September 9th, CMS has 90-days to respond, so we expect an approval or denial in early December of this year.  Regarding the incorporation of Quality Measures, Indiana Medicaid agreed with CMS that Quality Measures should be incorporated into the VBP program at a future date.  To that end, IHCA has been part of recent meetings with Indiana Medicaid and the Division of Aging to begin discussions on how Quality Measures could be incorporated in the future. 

Lastly, as you are aware, Indiana Medicaid and its contractors conducted satisfaction surveys of residents, family and staff this summer.  That data is not yet available for review or analysis, but will be in the coming month or so.  Once IHCA has this data, we will report back to the membership.
If you have any questions, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.

Indiana Medicaid Managed Care Report

The IHCA staff has engaged in multiple meetings and made presentations this summer concerning the study of managed care programming for the Aged, Blind and Disabled beneficiary group being conducted by the Family and Social Services Administration (FSSA).  The FSSA study is being conducted pursuant to a law that was passed in 2013 mandating such a report be made to the legislature’s Health Finance Commission by December 15, 2103.  For a summary of what the report must address, visit FSSA’s website on the topic at http://www.in.gov/fssa/4828.htm.  IHCA submitted initial comments to FSSA concerning its report and approach to the issue in mid-July. Click here for IHCA’s responses. You can view IHCA’s presentation that was made to FSSA’s internal committee at http://www.in.gov/fssa/files/IHCA_ABD_Taskforce_Presentation.pdf and watch the presentation at http://www.in.gov/fssa/4830.htm (see Indiana Health Care Association under the August 16th, 2013 heading).

e450B Process

The e450B process continues to be slow, despite increase staff assigned to process the submissions.  While the wait time for approval has decreased some, the Division of Aging is just now processing forms that were submitted in late July and early August.  IHCA has learned that the Division of Aging is working on a contract to obtain more personnel to assist with the e450B process.  In addition, the Division is working on a short-form e450B that should help move the process faster.  They are not sure of a completion date for the short-form, but hope it will not be any later than January 1, 2014.

The State will be holding a webinar in late October to continue to educate facilities about the e450B process.  Once that date is released, we will inform membership.  Also, the Division is working on a revised Resident Summary description and guidance in order to help streamline that portion of the e450B process.

If you have any questions, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.

IGT/UPL Distribution Methodology is Changing

On September 10, 2013, CMS approved Indiana Medicaid’s State Plan Amendment to change the way supplemental payments are distributed to non-state government operated or owned nursing facilities (i.e. county or city hospital owned nursing facilities).  The new methodology will calculate supplemental payments based on each facility’s Medicare Rate and adjusted Medicaid rate – in other words, it will be a facility-specific calculation.  Prior to this new methodology, the supplemental payment was an average amount that was paid to all participating hospitals.  This change results in some hospitals gaining and some losing supplemental payment funds.  Click here to read CMS’s approval letter.

If you have any questions, or need specific calculation information on the new methodology, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.

CMS Issues RAI Manual Updates Effective October 1, 2013

 CMS recently posted the fall updates to the RAI User’s Manual, which take effect on October 1. Among the important changes providers need to be familiar with are new items in Section K (swallowing/nutritional status) and Section O (special treatments, procedures and programs).  Additional clarification is also provided in Section G (activities of daily living) and on setting the assessment reference date (ARD) for Discharge assessments.  These changes will impact classification of residents into RUGs for payment purposes and should be reviewed carefully by center staff involved in care documentation and MDS assessments and coding.

In Section K, a new item is added to capture information about caloric and fluid intake via parenteral feeding, tube feeding or intravenously. 

In Section O, two new pieces of information are being captured.  First, centers will be required to report co-treatment minutes by entering the total number of minutes each discipline of therapy was administered to the resident in co-treatment sessions in the last 7 days. Second, centers will now be required to report the number of distinct calendar days on which at least 15 minutes of therapy services were provided in the past 7 days.

In Section G, item G0110, Activities of Daily Living (ADL), the manual updates relate to the “rule of three” and the use of the ADL Self-Performance Algorithm. Over the past several months, CMS has commented in a number of different venues regarding the intended application of the rule of three described in the RAI manual.  In these new updates, CMS clarifies the instruction that as the first step to determining the appropriate coding for this section, “When an activity occurs three or more times at any one level, code that level.” If this step applies to the situation, providers are instructed not to go on to apply the algorithm. New examples are included in this section to illustrate correct coding.
Finally, with regard to discharge assessments, CMS clarifies  that the ARD for a discharge assessment is always the date of discharge.

CMS also released a separate memorandum describing the transition process for implementation of these new items, effective October 1.  The transition policies will apply to determination of RUGs for individuals with assessment reference dates between October 1 and October 13.

Antipsychotic Drug Use is Declining

On August 27, CMS released data regarding antipsychotic drug use in nursing homes. Click here for the data and the CMS press release. Use has decreased across the country by 9.1 percent comparing first quarter of 2013 with last quarter of 2011.  At least eleven States have hit or exceeded a 15 percent target reduction, and Indiana saw nearly a 10% reduction (9.79%).

Affordable Care Act Communication Directory

The State of Indiana has published a communication directory for use when fielding questions from clients, patients, families, and even your friends related to the Affordable Care Act. Click here to access the directory. It is organized by General Topic with Subtopics, then provides referral information.  Although much of the ACA’s health care expansion and insurance provisions do not directly impact long term care, you may find this directory useful.

ISDH Health Facility Plan Review

As many are aware, the ISDH is behind in reviewing health facility plans for construction with 27 pending plans to be reviewed.  The ISDH Division of Long Term Care has re-arranged the plan review process so that Kim Rhoades will be directly involved with the plan review process rather than it being directed by ISDH engineers.  Mrs. Rhoades plans to contact the facility’s representative and architect to arrange for an in-person meeting at which time the facility and the architect will be required to walk through the submitted plans to explain how the plans comply with regulatory requirements and then sign an affidavit attesting to such compliance.  The ISDH hopes that this process will speed up plan review with the goal of clearing the existing 27 plans by December 31, 2013.

Residential Facility Survey Update

There were 37 Residential Care  citations issued by the ISDH in June, 33 of which were deficiency tags and 4 were offense tags.  Tag 273, Food & Nutritional Services, continues to be cited frequently with 4 citations in August for alleged failure to maintain food preparation and service areas in accordance with local sanitation and food handling standards.  Tag 273 is the most often cited tag in 2013.  Right behind this tag in terms of frequency is Tag 241 concerning administration of medication by licensed personnel or by a QMA.  Three facilities were cited for alleged failure to comply with Tag 241 in August.

For only the second and third time this year, Tag 41 was issued to two facilities for alleged failure to investigate and respond to complaints or grievances.  The low incidence of this tag is testament to the good work facilities do in responding to complaints when filed. Click here to see the summary of the August Residential Care Citations.

Incident Reporting – Changes Ahead

The IHCA was given a preview of an online Incident Reporting System that is being developed by the Indiana State Department of Health.  The online system will be housed in the same area as the existing online Survey System.  The online Incident Reporting System mimics the existing Incident Report Form in terms of content and work flow.  Accessing the online Incident Report Form will be limited to those with a log-in and password to the Survey System, and facilities may have more than one person with such access.

The online form will allow a user to begin completing an incident report and save that progress without having to complete it in one sitting so that the user can return to the form to later complete it and submit the form.  In order to submit the form, the user will have to complete all fields except the ‘Follow-up’ field.  Once submitted, the user will be able to track all submitted incidents reported.  In addition, once an incident is submitted, the user will receive an email reminder to submit the required follow-up report 3-days after the incident is submitted, thereby helping the user comply with the 5-day follow-up requirement.  The online Incident Reporting System will not include or cover applicable Crimes Reporting requirements under the Elder Justice Act.  Reports of reasonable suspicions of crimes will still have to be reported separately, but the ISDH is working on a web-form for that process as well that will be housed on a publically accessible portion of the ISDH website.

The ISDH expects that it will test the online Incident Reporting System in October, with a live release in November, and then require mandatory use of the online system as of January 2014.