COUNTDOWN DAY 3: Impact to State Case Mix
Federal regulations mandate that all nursing facilities, regardless of the Medicaid system in their state, must conduct patient specific MDS assessments, known as OBRA assessments, at specific intervals for each resident, regardless of their payer. Many states utilize these federally mandated MDS assessments to inform and calculate the case mix index (CMI). For decades, case mix states have adopted models for the MDS assessment that are similar to the Prospective Payment System (PPS) of their time, such as RUGs III or IV. However, beginning 10/1/2023, federal support for the calculation of RUG scores will end. States who continue to apply RUG methodology will have to implement the Optional State Assessment (OSA) which can no longer be combined with any other assessment. The MDS v. 1.18.11 will only support PDPM determinations. In an effort to prepare for this change, states that implement a Case Mix system, may be transitioning or have already transitioned to PDPM.
While case-mix methodologies vary from state-to-state, there are universal strategies to enhance CMI, regardless of individual state practices:
- Timing is everything: Ensure each member of the interdisciplinary team (IDT) has the most up to date calendar of quarterly and annual Assessment Reference Dates (ARDs).
- Verify your state plan as of 10/1/2023 for Case Mix determination and whether the OSA will be required.
- Ensure the IDT is trained to conduct interviews timely and accurately so that all relevant information is recorded (See Section GG Assessment Quick Card).
- Plan, implement, communicate, and assess processes for effectiveness regularly.
In the event your state is continuing to require the use of the OSA, the OSA Manual provides these instructions/coding tips:
- Not federally mandated, but may be mandated by state
- Contact state for clarification
- Must be a stand-alone assessment
Effective case mix management through thorough and complete MDS assessments are critical. Now more than ever, it is essential for each member of the IDT to be educated about the changes, enabling them to contribute their expertise accordingly. Navigating case mix management through evolving payment structures is challenging, but with effective systems in place, success can be both achievable and sustainable.
Be on the lookout for tomorrow’s blog: Quality Measure Updates
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