LAC 50:II.20007. Case-Mix Index Calculation [Formerly LAC 50:VII.1307]

A. The Resource Utilization Groups-III (RUG-III) Version 5.20, 34-group, index maximizer model shall be used as the resident classification system to determine all case-mix indices, using data from the minimum data set (MDS) submitted by each facility. Standard Version 5.20, or its successor, case-mix indices developed by CMS shall be the basis for calculating average case-mix indices to be used to adjust the direct care cost component. Resident assessments that cannot be classified to a RUG-III group, will be excluded from the average case-mix index calculation. 1. Prior to the July 1, 2025, rate setting, the RUG-III, Version 5.20, 34-group index maximizer model is used as the resident classification system to determine all case-mix indices. B. Effective as of the July 1, 2025, rate setting, PDPM case-mix groups and case-mix index weights effective October 1, 2024, as listed in table 5 from the final SFY PPS payment rule for FY 2025 (CMS-1802-F) are used as the resident classification system to determine all case-mix indices, using data from the MDS submitted by each facility. PDPM case-mix index weights effective October 1, 2024, developed by CMS, shall be used to adjust the direct care cost component. A hierarchal methodology is used to determine the individual CMIs. A blended approach is used to determine the case-mix indices to adjust the direct care cost component. The percentages used for blended approach are as follows: 1. physical therapy: 15 percent; 2. occupational therapy: 15 percent; 3. speech language pathology: 8 percent; 4. non-therapy ancillary: 12 percent; and 5. nursing: 50 percent. C. Assessments completed prior to January 1, 2025, that cannot be classified to a PDPM case-mix group, will be excluded from the average case mix index calculations. D. Assessments completed on or after January 1, 2025, that cannot be classified to a PDPM case-mix group, will be assigned the lowest CMI value relative for each PDPM component. E. Each resident in the nursing facility with a completed and submitted assessment, shall be assigned a PDPM case-mix groups, based on the following criteria. 1. Prior to the January 1, 2017, rate setting, the RUG-III group, or its successor, is calculated based on the resident's most current assessment, available on the last day of each calendar quarter, and shall be translated to the appropriate case mix index. From the individual resident case mix indices, two average case mix indices for each Medicaid nursing facility provider shall be determined four times per year based on the last day of each calendar quarter. 2. Effective as of the January 1, 2017, rate setting, the RUG-III group, PDPM group, will be calculated using each resident MDS assessment transmitted and accepted by CMS that is considered active within a given calendar quarter. These assessments are then translated to the appropriate case mix index. The individual resident case mix indices are then weighted based on the number of calendar days each assessment is active within a given calendar quarter. Using the individual resident case mix indices, the calendar day weighted average nursing facility-wide case mix index is calculated using all residents regardless of payer type. The calendar day weighted nursing facility-wide average case mix index for each Medicaid nursing facility shall be determined four times per year.