The New York State Department of Health has published the final regulations, adopting the per consumer per month (referred to as “PMPM”) reimbursement methodology for CDPAP. The final regulations are available on page 7 HERE, and are effective today, January 13, 2021.
In summary, CDPAP fiscal intermediaries that have contracts with LDSSs and bill Medicaid directly will be reimbursed in accordance with the PMPM formula. Based on thousands of comments submitted by fiscal intermediaries and associations in opposition to the proposed PMPM formula, the DOH has issued regulations establishing the following PMPM rates:
Tier 1: (1 – 159 hours) will be reimbursed at the PMPM rate of $145
Tier 2: (60 – 479) will be reimbursed at the PMPM rate of $384
Tier 3: (480 +) will be reimbursed at the rate of $1,036
For providers that have contracts with MLTCs to provide CDPAP services, they will continue to be reimbursed at the negotiated rates. The regulations specifically provide that the PMPM rates may not impact the ability of managed care organizations to reimburse fiscal intermediaries for their administrative costs, as negotiated by the managed care and provider organizations.
In summary, the PMPM rates establish a new reimbursement model for LDSS CDPAP cases, and they signal the potential for reimbursement cuts to MLTC-dependent fiscal intermediaries. However, providers knew the rate cuts were on the horizon and, thus, the fact that there is a cut should not be a surprise. But, providers should be encouraged and celebrate the fact that the published and final PMPM rates are DOUBLE (and in some tiers more than double) the rates that had been originally proposed by the DOH. The State’s final regulations (and increased rates) reflect the feedback of the thousands of providers, consumers, workers, associations and lobbying groups – CDPAC included – who submitted information to the State, opposing the proposed PMPM rates. Furthermore, the spirit of the changes, and the detailed comments in the Register should be helpful to providers who have been facing pressure from MLTCs that have aggressively sought to reduce reimbursement rates and push a PMPM structure onto providers. With these regulations in place, and the State’s emphasis that payors provide and fund the fiscal intermediaries’ administrative costs, providers should more confidently seek fair and reasonable reimbursement rates from plans.
If you have any questions about the PMPM regulations, or negotiating rates with MLTCs, please let us know.