Demonstration of Home Health Agencies Settlement for Dual Eligibles for the State of New York

CMS is conducting a pilot program with the States of Connecticut, Massachusetts, and New York, that utilizes a sampling approach to determine the Medicare share of the cost of home health service claims for dually eligible beneficiaries that were originally submitted to and paid by the Medicaid agencies. This sampling will be used in lieu of individually gathering Medicare claims from home health agencies for every dually eligible Medicaid claim the state has possibly paid in error. This process will eliminate the need for the home health agencies (HHA) to assemble, copy, and submit huge numbers of medical records, as well as the need for the regional home health intermediary (RHHI) to review every case. The demonstration consists of two components: (1) an educational initiative to improve the ability of all parties to make appropriate coverage recommendations for crossover claims and (2) a statistically valid sampling methodology to be applied in settlement of claims paid by Medicaid for which the State believes may have a potential to also be covered by Medicare.