Nursing Facility Case-Mix Payment Changes Announced

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare®

CMS posted an informational bulletin on December 6, 2018 outlining the upcoming Medicaid case-mix payment changes as they relate to the implementation of the PDPM (Patient Driven Payment Model) classification/reimbursement system on October 1, 2019.

These are the key points for the change:

  • On October 1, 2020 CMS will no longer support RUG-III and RUG-IV case-mix methodologies via the Minimum Data Set (MDS).
  • For States that rely on these assessments for calculating their case-mix group, CMS has created an optional assessment so that Medicaid payment is not adversely impacted when PDPM is implemented on October 1, 2019. States will have some flexibility in crafting policies associated with this assessment. The optional assessment will be effective from October 1, 2019 through September 30, 2020.
  • CMS will be removing several MDS data elements over the next few years. Many MDS data elements used in RUG-III and RUG-IV are no longer required for Federal purposes. With the removal of data elements, RUG-III and RUG-IV will no longer be functional.
  • States that continue to use RUG-III or RUG-IV after October 1, 2020 will need to implement a new process to gather the needed data.

For those of us that follow the MDS, PPS and Medicaid Case-Mix world, this is an expected announcement. To receive this news at this time, is a gift. We have time to prepare for future announcements!