1. J. Brandon Durbin 2950-50th Street 909-18th St.
Lubbock, Texas Plano, Texas
Fax

3. Topics Medicaid & State programs
Medicare issues and legislative update
Medicare Group Appeals

4. M N A I Y R U O L E S H G T P C J D B W F Z V K

5. E I A M D C Waiver Issues Medicaid DSH Nursing Facility MPA (UPL) NAIP
Renewal
Deferral
UCC Issues
Medicaid DSH
Nursing Facility MPA (UPL)
NAIP
Payment reforms (VBP, etc)

6. M N A I Y R U O L E S H G T P C J D B W F Z V K

7. Waiver Renewal – DSRIP CMS Rural Providers Streamline this process
Prototype projects for regions
More realistic valuations
Rural Providers
Minimum allocations
Meaningful RURAL projects in the prototypes

8. Waiver Renewal – UCC CMS does not like UCC
Florida is a case study for our renewal
CMS back at the table for Florida
CMS is pushing “expansion”, but this is DOA
Issues are not realistic
Even with expansion we would have significant UCC, so we must renew UCC
Florida is getting renewal of their UCC (LIP)

9. Waiver Renewal - UCC Alternatives
Rural Providers have close to cost on traditional, and if the riders pass there is very little UCC for Medicaid. Its all about the uninsured.
Alternatives such as a provider assessment, provider taxes, local provider fees will not provide funds for rural providers, as this just increases the Medicaid payments.

10. Funding Mechanics
The deferral was caused by CMS letter to State Medicaid Directors
TX position - Cannot legislate or rule make by memo or letter
Established this method at the inception of the waiver
Will it Continue
The lawyers feel that Texas is legal, and that the use of a memo to change federal law is not applicable.
A state wide provider tax is DOA

11. M N A I Y R U O L E S H G T P C J D B W F Z V K

12. Funding Time Frames last of 2014
UC IGT due June 5th.
Their will be a commitment date before
May 6th – 15th
UC paid June 30, 2015
Rural hospitals are not considered “Transferring”
Even though you IGT.

13. Speeding up the process for 2015
Request participation in May 2015 for 2015
Tools in June 2015
Increasing the prepopulated data including cost reports should help, as long as there are not too many errors.

14. Local Provider Fees Local provider fee through the County
South Texas did in 2013 – Funded $160M in UCC
2015 bills – Waco, Temple, Beaumont, Bryan/College Station, Texarkana, Longview, possible for Tyler.
Will fund $476M in UCC if all bills enacted
$316M is new to program
This will cause more stress on the system
Some markets will be disrupted
RHP 1 & 16 will have the greatest impact

15. Haircuts In 2013 this was 21.6% for those with fully funding IGT.
In 2014 (DY3), with no other changes other than the base decreasing this would be 31.6%
The win last year was to exempt Rider 38 hospitals from most of the cuts, projected haircut as follows:
DY3 9.4%
DY4 14.2%
DY5 20.5%

16. Rider 38 Hospitals Hospitals in counties less than 60,000 in 2010
Sole Community Hospitals
Rural Referral Hospitals
Critical Access Hospitals

17. Other Haircuts
Other Haircuts are very difficult to estimate, with the new pool system. Based on PY commitment levels, this is about 15%, but estimates are up to 25%
With LPPF, this would increase about an additional 10% in DY4, plus the overall reduction in the UCC pool.
The Private programs will have the most impact. Possible rolling back in 2015 about 15% of all community benefits.

18. M N A I Y R U O L E S H G T P C J D B W F Z V K

19. S D H
DSH 2015 application date is the same as the UC tool – May 2015 for requesting the tool.
DSH 2014 IGT date May 4th, 2015
Payment date is May 29th, 2015
Everything is pending the IGT.
Two are resisting an IGT, but other 6 have committed to take their share
How could a District forego $20M+ net for principle?

20. S D H DSH rules are already published
Still issues with the transferring IGT.
State GR for future years is (pick one)
Nonexistent
Iffy
Reduced
Certain
There is a better way to handle this

21. S D H
If we look at the effect of GR on the DSH program , the GR has about $300M net impact.
Rural is about $12-13M benefit
The Outpatient and inpatient Rider is about $80M.
The impact of $300M in GR for a supplemental MCO payment is $700M+
Rates are better than DSH GR

22. S D H
Rural DSH issues
IGT will be on 50% of the amount, due to State GR in 2014
Future amounts will be based on 100% IGT, due to no State GR.
Pass 3 will play a small part in future years ($30M) in total funding, with about half going to non rural public hospitals.
Will help on the UCC haircuts

23. S D H Will need to revise DSH estimates if Rider on Outpatient passes
The rider will decrease UCC cost & DSH capacity
Reducing haircut
You will get more overall money, but much of it will come in the way of claim payments

24. M N A I Y R U O L E S H G T P C J D B W F Z V K

25. H N U L P
HHSC has changed the name to Minimum Payment Amount Program(MPAP)
New program goes through the Managed Care Organizations (MCO’s)
Closed program for now, but needs to be looked at for beyond 2016
Need to rewrite the rules for the future

26. H U L N P Future program will have an emphasis on quality programs
Probably HHSC proscriptive projects and managed by MCO’s
Also need to solve some funding problems
MCO’s have identified many issues and are willing to help fix them

27. H U L N P IGT’s were based on data from 2013-14 through April of 2014
Due to reductions in nursing home admissions, the MCO’s will probably make a profit on this process, which is one of the issues the MCO’s seem willing to mitigate
IGT funding requirements and timing on MPAP payments are disruptive to cash flows

28. H N U L P
The overall NH census has been reducing about 1-3% per year in most regions, before managed care.
The managed care companies want to decrease utilization and have case workers actively working to reduce census

29. Minimum Payment Amount Scenario in a Declining Census Model
(Impacts Nursing Facility MPAP Payments but does not impact MCO Rate Enhancements for MPAP)
Census in 2014
Annual Estimated MPA
Actual Census
Actual Payment
Variance A 50
2,190,000
918,705 - B 70
3,066,000
1,286,187 68
2,978,400
(87,600) C 60
2,628,000
1,102,446 62
2,715,600
87,600 D 90
3,942,000
1,653,669 87
3,810,600
(131,400) E 40
1,752,000
734,964 37
1,620,600 85
3,723,000
1,561,799 84
3,679,200
(43,800)
395
17,301,000
7,257,770
388
16,994,400
(306,600)

30. H U L N P So what happens to that $306,6oo in the example?
That becomes MCO profit.
The real number when extrapolated and without the MCO’s reducing any census is about $9M that will not be realized based on these assumptions.
If they are successful in reduction of residents that number grows…

31. H N U L P
We have met with TORCH, Kevin Reed, Kevin Nolting and Billy Millwee (who represents the MCO’s)
The MCO’s are agreeable to a solution where they will distribute the profit, as long as MCO can mitigate any losses.
If MCO has risk for losses, the whole process may have bigger issues

32. Census in 2014
Annual Estimated MPA
Actual Census
Actual Payment
Correct IGT
Variance A 50
2,190,000
918,705 - B 70
3,066,000
1,286,187 68
2,978,400
1,249,439
(36,748) C 60
2,628,000
1,102,446 62
2,715,600
1,139,194
36,748 D 90
3,942,000
1,653,669 87
3,810,600
1,598,547
(55,122) E 40
1,752,000
734,964 37
1,620,600
679,842 85
3,723,000
1,561,799 84
3,679,200
1,543,424
(18,374)
395
17,301,000
7,257,770
388
16,994,400
7,129,151
(128,619)

33. H N U L P
Also need to solve a fairness of IGT issue. The IGT is based on historical data and this may require an adjustment to align with actual data.
Program would be jointly administrated by TORCH and TAHP (MCO Association)
Cost should be minimal, and should more than be covered by profits from MCO profit distribution.

34. H N U L P
MCO’s are also willing to make a prospective supplemental payment, to assist in the cash flow.
Pay enough additional money on a quarterly basis to solve cash flow issues
All public providers need to participate
This is very similar to other programs in other states using MCO arrangements

35. E I A M D C New Program – NAIP Network Access Improvement Program
Mini DSRIP program –less bureaucracy
Year by Year program – Not long term projects
We are working on a few projects
School TeleMed
TeleNICU™ through Dallas Children's
More to come on this in the coming months

36. E I A M D C Rates & Value Based Purchasing
VBP is the buzzword for payment reform
Non Emergent ED was a bad one, that hopefully TORCH can get eliminated
Very difficult to use VBP where the hospital has no real control over the care.
It is continuing and will grow to make up most of your payment programs
EAPG are still being pushed for the MCO.
We need the rural rider on outpatient!!!

37. Telehealth This has boomed in the last few years
Urban to rural is a traditional focus
Needs sustainability, not just referral based
Possible new programs
TeleNICU
Schools
Nursing Homes
TeleED and after hours clinics– Lots of potential savings.

38. Medicare Issues EHR payments and missing MCO data
No Shadow bill = No payment
CAH Swing Bed Utilization requires MCO for advantage plans be included in total.
Will dilute SB reimbursement
Make sure advantage is paying swing bed rates
Low Volume Group Appeal
We have one based on using actual utilization, not two year old data
Average is $100K per provider

39. Medicare Legislation - Pending
Extension of Low-Volume Hospital Adjustment
Extension of Medicare Dependent Hospitals program
Extension of Therapy Cap Exceptions Process
Enforcement delay of Two-Midnight Policy
Medicare Ambulance Add-on Payments – Extends the add-on payment for ground ambulance services, including in super rural areas
Medicare Home Health Rural 3% Add-On

40. Questions