Ch. 7, § 16. HealthCare Case Mix Acuity Adjustment

(a) Healthcare prices will be paid using a starting fixed price that is the same for all facilities. The fixed price will be adjusted for each individual nursing facility on a quarterly basis based on each nursing facility's Medicaid case mix index to reflect the case mix of that nursing facility's Medicaid residents in a certain quarter. The case mix adjustment will be calculated by taking the fixed starting price times each nursing facility's weighted average Medicaid case mix index divided by the statewide average Medicaid case mix index for each quarter. (b) Applicable Case Mix Index (CMI). The Medicaid CMI used in establishing each nursing facility's rate is calculated based on the weighted average assessment for each Medicaid resident in the nursing facility in the prior quarter where an MDS assessment was completed and successfully transmitted to the QIES ASAP system. (i) The CMI is recalculated quarterly and each nursing facility's healthcare component rate is adjusted accordingly. (ii) In the event that a nursing facility's Medicaid CMI is zero, the nursing facility's average case mix score from the most recent quarter will be used. If there is no data for the previous quarters, they will receive the statewide average Medicaid case mix index score from the prior quarter. (c) Minimum Data Set (MDS). A set of screening, clinical, and functional status elements, including common definitions and coding categories, that forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The version of the assessment document used for rate setting is version 3.0. Subsequent versions of the MDS will be evaluated and incorporated into rate setting as necessary. (d) Case Mix Index (CMI). A numeric score assigned to each nursing facility resident, based on the resident's physical and mental condition that projects the amount of relative resources needed to provide care to the resident. (i) The Department will use the Patient Driven Payment Methodology (PDPM) case mix classification methodology. The nursing facility case mix classifications will be used to calculate rates. (ii) For the July 1, 2015 rate quarter, the case mix weight will use the most current MDS assessment for all Medicaid residents as of April 1, 2015. Beginning with the October 1, 2015 quarter and all subsequent quarters, the case mix weight for each resident of a nursing facility for each prior quarter is based on data from MDS assessments completed for the resident and accepted into the QIES ASAP System and weighted by the number of days the resident assessment was in each case mix classification group. (A) A default case mix group will be established for cases in which the resident dies or is discharged prior to completion of the resident's initial assessment. The default case mix group and case mix weight for these cases will be designated by the Department. (B) A default case mix group will also be established for cases in which there is an untimely assessment for the resident. The default case mix group and case mix weight for these cases must be designated by the Department. (iii) The nursing facility Medicaid case mix average will be determined by multiplying the case mix weight of each Medicaid resident by the number of days the resident was at each particular case mix classification group, and then averaging. (A) The payment source for a resident assessment is considered to be Medicaid if the assessment is a non-PPS assessment where MDS item A0700 Medicaid Number is submitted with a valid Medicaid number. (B) State-Wide Average Medicaid Case Mix Index. The simple average of all nursing facilities Medicaid case mix indexes used in establishing the reimbursement limitation each quarter. (e) Nursing Facility: MDS Reviews. The following Minimum Data Set (MDS) reviews will be conducted. (i) Prior to each rate quarter, the Department will send each nursing facility a preliminary report of its resident roster, a listing of residents' assessments, PDPM Nursing Component classification, number of days for the PDPM classification, case mix index, and payment source. The nursing facility must review the preliminary report and submit missing assessments or corrections to the QIES ASAP system prior to the final rate determination. (ii) If the Department finds errors in the MDS data that result in an incorrect case mix index, the nursing facility's rate will be retroactively adjusted, for all quarters containing the incorrect assessment, and the Department will determine what amount is due to or from the nursing facility. This does not include residents who received the default classification due to incomplete or inconsistent MDS data.