New York State Adopts Case Mix Regulations

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

On June 2, 2021, the State of New York posted amended “regulations concerning the operating component of rates of Medicaid reimbursement for nursing homes.”  NY will use larger data sets within the case mix period to determine case mixes, for purposes of calculating rates for periods beginning July 1, 2021.

These regulations calculate the case mix adjustment by viewing acuity data for all relevant dates, rather than a single date, which can lead to inaccurate and distorted results.

NY LTC facilities will no longer be required to upload census data separately from the Minimum Date Set (“MDS”) data. The streamlining of the MDS process will reduce administrative burdens on the provider and increase accuracy in Medicaid rates of payment.  Current state regulations give the Department discretion to cap changes in a facility’s case mix index at 5%.  The Department does not intend to exercise this discretion and, therefore, is repealing this provision.

  • For the case mix periods beginning on and after July 1, 2021, the case mix adjustment to the direct component of the price shall be made in January and July of each calendar year and shall use all Medicaid-only case mix data submitted to CMS applicable to the previous six-month period (e.g., April – September for the January case mix adjustment; October – March for the July case mix adjustment).
  • Case mix adjustments to the direct component of the price for facilities for which facility specific case mix data is unavailable or insufficient shall be equal to the [base year] previous case mix of the peer group applicable to such facility.
  • The adjustments and related patient classifications for each facility shall be subject to audit review by the Office of the Medicaid Inspector General[.], and/or other agents as authorized by the Department.
  • For case mix periods beginning on and after July 1, 2021, the operator of a proprietary facility, an officer of a voluntary facility, or the public official responsible for the operation of a public facility shall submit to the Department a written certification, in a form as determined by the Department, attesting that all of the “minimum data set” (“MDS”) data reported by the facility and submitted to CMS is complete and accurate.
  • In the event the MDS data reported by a facility results in a percentage change in the facility’s case mix index of more than five percent, then the impact of the payment of the Medicaid rate adjustment attributable to such a change in the reported case mix may be limited to reflect no more than a five percent change in such reported data, pending a prepayment audit of such reported MDS data, provided, however, that nothing in this paragraph shall prevent or restrict post-payment audits of such data as otherwise provided for in this subdivision.

LeadingAge New York has posted a notification regarding this action as well that’s worth the read. It provides additional references related to this change to CMI.