DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-26-12
Baltimore, MD 21244-1850
MS
CENTW fOR MEDICARE & MWICAllJ SERVICES
CENTER FOR MEDICAID & CHIP SERVICES
Financial Management Group
APR 19 2016
Jason A. Helgerson
State Medicaid Director
Deputy Commissioner
Office of Health Insurance Programs
NYS Department of Health
Coming Tower (OCP-1211)
Albany, NY 12237
RE: State Plan Amendment (SPA) TN 15-0030
Dear Mr. Helgerson:
We have reviewed the proposed amendment to Attachment 4.19-D of your Medicaid State Plan
submitted under transmittal number (TN) 15-0030. Effective April l, 2015 this amendment
revises temporary Vital Access Provider I Safety Net Provider (VAP/SNP) enhanced payments
for 43 nursing homes.
We conducted our review of your submittal according to the statutory requirements at sections
l 902(a)(2), l 902(a)(l3), l 902(a)(30)and l 903(a) of the Social Security Act and the
implementing Federal regulations at 42 CFR Part 447. This is to inform you that New York
15-0030 is approved effective April 1, 2015 and have enclosed the CMS-179 and approved plan
pages.
If you have any questions, please contact Joanne Hounsell at 212-616-2446.
Sincerely,
Kristin Fan
Director
Enclosures
DEPARTMENT OF HEALTH AND HUMAN SERVICES
HEALTH CARE FINANCING ADMINISTRATION
FORM APPROVED
OMB NO. 0938-0193
TRANSMITTAL AND NOTICE OF APPROVAL OF
STATE PLAN MATERIAL
l. TRANSMITTAL NUMBER:
2. STATE
15-0030
New York
3. PROGRAM IDENTIFJCATION: TITLE XIX OF THE
FOR: HEALTH CARE FINANCING ADMINISTRA TJON
SOCIAL SECURl'.fY ACT (MEDICAID)
TO: REGIONAL ADMINISTRATOR
HEALTH CARE FINANCING ADMJNISTRATION
DEPARTMENT OF HEALTH AND HUMAN SERVICES
5. TYPE OF PLAN MATERIAL (Check One):
4. PROPOSED EFFECTIVE DATE
April 1, 2015
·~~-'--~~~~~~~~~~~~~~~~~-!
0
NEW STATE PLAN
0 AME~DMENT TO BE CONSlDERED AS NEW PLAN
[8J AMENDMENT COMPLETE BLOCKS 6 THRU l 0 IF THIS IS AN AMENDMENT 'e arate Transmittal or each amendment) 6. FEDERAL STATUTE/REGULATION CITATION:
7. FEDERAL BUDGET IMPACT: (in thousands)
a. FFV 04/01115-09/30/15 $13,750.00
§1902(a) of the Social Security Act, and 42 CFR 447
b. FFV 10/01115 -09/30/16 $27,500.00
8. PAGE NUMBER OF THE PLAN SECTION OR A'ITACHMENT:
Attachment 4.19-D: Pages 47(aa)(4), 47(aa)(5), 47(aa)(6), 47(aa)(7),
47(aa)(8), 47(aa)(9), 47{aa)(l0)
9. PAGE NUMBER OF THE SUPERSEDED PLAN
SECTION OR ATIACHMENT (If Applicable):
Attachment 4.19-D: Pages 47(aa)(4), 47(aa)(5), 47(aa)(6),
47(aa)(7), 47(aa)(8)
10. SUBJECT OF AMENDMENT:
Safety NetNAP - CINERGY (15/16, 16/17)
(FMAP=50%)
l l. GOVERNOR'S REVIEW (Check One):
0
[8] GOVERNOR'S OFFICE REPORTED NO COMMENT
0
0
OTHER, AS SPECIFIED:
COMMENTS OF GOVERNOR'S OFFICE ENCLOSED
NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMlTTAL
12. SIONA
NCY OFFICIAL:
16. RETURN TO:
New York State Department of Health
~:!!----------l Division of Finance and Rate Setting
99 Washington Ave - One Commerce Plaza
-14-.-T-IT_L_E_:_M_e_d_ic_,a1.....d_D_i-re-ct_o_r-------------l Suite 1460
Albany, NY 12210
De artment of Health
15. DATE SUBMITTED:
17. DATE RECElVED: JUN 2 6 2015
FOR REGIONAL OFFICE USE ONLY
18. DATE APPROVED:
APR 19 2016
PLAN APPROVED-ONE COPY ATfACHED
OF ~Gf!_AL OF~CIAL:
19. EFFECTIVE DATE OF APPROVED MATERI.AL:
20. SIONA
21. TYPED NAME:
22. n~ir
23. REMARKS:
FORM HCFA-179 (07-92) L.cf-cr ptvt.~
Attachment 4.19-D - Part I
New York
47(aa)(4)
Temporary Rate ~djustments for Mergers, Acquisitions, Consolidations, Restructurings, and
Closures - Nursing Homes
A temporary rate adjustment will be provided to eligible residential health care providers that are subject
to or impacted by the closure, merger, and acquisition, consolidation or restructuring of a health care
provider. The rate adjustment is intended to:
•
•
•
Protect or enhance access to care;
Protect or enhance quality of care; or
Improve the cost effectiveness.
Eligible residential health care providers, the amount of the temporary rate adjustment, and the duration
of each rate adjustment period shall be listed in the table which follows. The total adjustment amount for
each period shown below will be paid quarterly during each period in equal installments. The temporary
payment made under this section will be an add-on to services payments made under this Attachment to
such facilities during the quarter.
To remain eligible, providers must submit benchmarks and goals acceptable to the Commissioner and
must submit periodic reports, as requested by the Commissioner, concerning the achievement of such
benchmarks and goals. Failure to achieve satisfactory progress in accomplishing such benchmarks and
goals will result in termination of the provider's temporary rate adjustment prior to the end of the
specified timeframe. Once a provider's temporary rate adjustment ends, the provider will be reimbursed
in accordance with the otherwise applicable rate-setting methodology as set forth !n this Attachment.
Temporary rate adjustments have been approved for the following providers in the amounts and for the
effective periods listed.
Nursing Homes:
Gross Medicaid Rate
Provider Name
Adiustment
$6.694
Rate Period Effective
$723.872
01/01/2014- 03/31/2014
04/01/2014 - 03/31/2015
Adirondack Medical Center - Uihlein
Living Center
$2.273,884
$2.359,369
$821.793
01/01/2014- 03/31 '2014
04/01/2014 - 03/31 '2015
04/01/2015 - 03/3li 2016
Adirondack Tri-County Nursing &
Rehabilitation Center, Inc.
$225.680
$1.369.690
01/01/2014- 03/31/2014
04/01/2014 - 03/31/2015
Adirondack Medical Center - Mercy
UvinQ Center
*Denotes provider is part of CINERGY Collaborative.
TN _
__i#!?:,.:1~5L
...¥Q0~311!.!0.e...-_ __
Supersedes TN
#14-QQ39
A_PR_l_9_20_16_ _
Approval Date _ _
APR 01 2015
Effective Date _ _ _ _ _ _ _ __
Attachment 4.19-D - Part I
New York
47(aa}(S)
Nursing Homes (Continued):
Provider Name
Amsterdam Nursing Home Corp
(Amsterdam House)*
Beth Abraham Health Services*
Bronx-Lebanon Special Care Center*
01/01/2015 - 03/31/2015
788 294
798 912
Brooklyn United Methodist Church
Home*
Buena Vida Continuing Care & Rehab
ar*
Cabrini Center for Nursing*
Carmel Richmond Healthcare and
Rehabilltation Center*
1096 359
Center For Nursing & Rehabilitation
Inc*
Chapin Home for the Aging*
771403
781 794
780 065
*Denotes provider is part of CINERGY Collaborative.
TN
Approval Date _ _,g.AP1...1.R.;i.......a..1.,fiL9_..2_01_6_ _ __
#15-QO~O
Supersedes TN
#14-QQ39
Effective Date _ _ _A_P_R...;:;.0-=-1-=2.;;;.:01:.:.:.-5______
Attachment 4.19-D - Part I
New York
47(aa)(6)
Nursing Homes (Continued):
*Denotes provider is part of CINERGY Collaborative.
_ _ __ Approval Date __
A_PR_l9_._20_16_ __
Supersedes TN _ _..#-=1......-=0=0.....
4.. 39..._
Effective Date _ _ _
A_PR_O_l_20_1_5- ­
TN _
..
_...#~1.,,5._· 0-03~0-
Attachment 4.19-D - Part I
New York
47(aa)(7)
Nursing Hgmes {Cgntinued):
Gross Medicaid Rate
Provider Name
Ad-ustment
Jamaica Hospital Nursing Home Co
764 892
775195
773 481
Inc*
· Jewish Home Llfecare Henry and
Jeanette Weinberg Campus Bronx*
Jewish Home Lifecare Manhattan*
Jewish Home UfeCare Sarah Neuman
Center*
Lutheran Augustana Center for
Extended Care & Rehab*
Margaret Tietz Center For Nursing
care Inc*
Mary Manning Walsh Nursing Home
Co Inc*
II
Menorah Home And Hospital For
Rehabilitation and Nursing*
l;
441177
447120
446131
I Methodist Home for Nursing and
I Rehabilitation*
*Denotes provider is part of CINERGY Collaborative.
TN
_---:.#::....:1:.:5:....:·P~0....,,3"""0_ _ __
Supersedes TN
#1!-0039
Approval Date _ _A_PR_1_9_2_0f_6_ _
Effective Date _ _
AP_R,_..;0:;...;1=--::.::20;..::.;15.____ _ Attachment 4.19-D - Part I
New York
47(aa)(8)
Nursing Homes (Continued):
Northeast Center for Special Care
*Denotes provider is part of CINERGY Collaborative.
TN
Approval Date __A_P_R.....,1.......9_20_16_ __
#15-0030
Supersedes TN
#14-0039
Effective Date _ _A_P_R_0_1_2_01_5_ _
Attachment 4.19-D - Part I
New York
47(aa)(9)
Nursing Homes (Continued):
*Denotes provider is part of CINERGY Collaborative.
TN _
___.:;#i;;.:li=.mS:....:-OE.:iQiC.1113~0:--_ Supersedes TN
NEW
Approval Date _ _
AP_R_1_9_20_16_ __
Effective Date _ _A_P_R_o_1_2_0_1s_ __
Attachment 4.19-D - Part I
New York
47{aa)(10)
Nursing Homes !Continued):
*Denotes provider is part of CINERGY Collaborative.
TN
~__.#~1-5_-_0=03_0...._~
Supersedes TN
NEW
Approval Date _ _A.. _P.R.....
. . . l ......
9_._2~016--
Effective Date _ _
A_PR_0_1_20_15_ __