Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE › Part III - Nursing Home Payment System Appendices › Appendix IV - Resource Utilization Groups (RUGs) › Section 12VAC30-90-306 - Case-mix index (CMI)

Current through Register Vol. 40, No. 24, July 15, 2024
A.
					 Effective for dates of service beginning July 1, 2001, through June 30, 2014,
					 nursing facility case-mix indices shall be applied as described in this
					 subsection. Each resident in a Virginia Medicaid certified nursing facility on
					 the last day of the calendar quarter with an effective assessment date during
					 the respective quarter shall be assigned to one of the RUG-III 34
					 groups.
B. Effective for dates of
					 service on or after July 1, 2014, nursing facility reimbursement described in
					 12VAC30-90-44 shall be based on the case-mix or RUG weights as described in
					 this subsection. Standard case-mix indices, developed by CMS for the Medicaid
					 population (B01), shall be assigned to each of the RUG-III 34 groups as
					 indicated in Table III.
Table III
Case-Mix Indices (CMI)
RUG Category
RUG Description
CMS "Standard" B01 CMI Set
RAD
Rehabilitation All Levels / ADL 17-18
1.66
RAC
Rehabilitation All Levels / ADL 14-16
1.31
RAB
Rehabilitation All Levels / ADL 10-13
1.24
RAA
Rehabilitation All Levels / ADL 4-9
1.07
SE3
Extensive Special Care 3 / ADL >6
2.10
SE2
Extensive Special Care 2 / ADL >6
1.79
SE1
Extensive Special Care 1 / ADL >6
1.54
SSC
Special Care / ADL 17-18
1.44
SSB
Special Care / ADL 15-16
1.33
SSA
Special Care / ADL 4-14
1.28
CC2
Clinically Complex with Depression / ADL
								  17-18
1.42
CC1
Clinically Complex / ADL 17-18
1.25
CB2
Clinically Complex with Depression / ADL
								  12-16
1.15
CB1
Clinically Complex / ADL 12-16
1.07
CA2
Clinically Complex with Depression / ADL
								  4-11
1.06
CA1
Clinically Complex / ADL 4-11
0.95
IB2
Cognitive Impairment with Nursing Rehab / ADL
								  6-10
0.88
IB1
Cognitive Impairment / ADL 6-10
0.85
IA2
Cognitive Impairment with Nursing Rehab / ADL
								  4-5
0.72
IA1
Cognitive Impairment / ADL 4-5
0.67
BB2
Behavior Problem with Nursing Rehab / ADL
								  6-10
0.86
BB1
Behavior Problem / ADL 6-10
0.82
BA2
Behavior Problem with Nursing Rehab / ADL
								  4-5
0.71
BA1
Behavior Problem / ADL 4-5
0.60
PE2
Physical Function with Nursing Rehab / ADL
								  16-18
1.00
PE1
Physical Function / ADL 16-18
0.97
PD2
Physical Function with Nursing Rehab / ADL
								  11-15
0.91
PD1
Physical Function / ADL 11-15
0.89
PC2
Physical Function with Nursing Rehab / ADL
								  9-10
0.83
PC1
Physical Function / ADL 9-10
0.81
PB2
Physical Function with Nursing Rehab / ADL
								  6-8
0.65
PB1
Physical Function / ADL 6-8
0.63
PA2
Physical Function with Nursing Rehab / ADL
								  4-5
0.62
PA1
Physical Function / ADL 4-5
0.59
C. There shall be four "picture dates" for
					 each calendar year: March 31, June 30, September 30 and December 31. Each
					 resident in each Medicaid-certified nursing facility on the picture date with a
					 completed assessment that has an effective assessment date within the quarter
					 shall be assigned a case-mix index based on the resident's most recent
					 assessment for the picture date as available in the DMAS MDS
					 database.
D. Using the individual
					 Medicaid resident case-mix indices, a facility average Medicaid case-mix index
					 shall be calculated four times per year for each facility. The facility average
					 Medicaid case-mix indices shall be used for case-mix neutralization of resident
					 care costs and for case-mix adjustment.
1.
					 During the time period beginning with the implementation of RUG-III up to the
					 ceiling and rate setting effective July 1, 2004, the case-mix index
					 calculations shall be based on assessments for residents for whom Medicaid is
					 the principal payer. The statewide average Medicaid case-mix index shall be a
					 simple average, carried to four decimal places, of all case-mix indices for
					 nursing facility residents in Virginia Medicaid certified nursing facilities
					 for whom Medicaid is the principal payer on the last day of the calendar
					 quarter. The facility average Medicaid case-mix index shall be a simple
					 average, carried to four decimal places, of all case-mix indices for nursing
					 facility residents in the Virginia Medicaid-certified nursing facility for whom
					 Medicaid is the principal payer on the last day of the calendar
					 quarter.
2. The facility average
					 Medicaid case-mix index shall be normalized across all of Virginia's
					 Medicaid-certified nursing facilities for each picture date. To normalize the
					 facility average Medicaid case-mix index, the facility average Medicaid
					 case-mix index is divided by the statewide average Medicaid case-mix index for
					 the same picture date.
3. The
					 department shall monitor the case-mix, including the case-mix normalization and
					 the neutralization processes, indices during the first two years following
					 implementation of the RUG-III system. Effective July 1, 2004, the statewide
					 average case-mix index may be changed to recognize the fact that the costs of
					 all residents are related to the case-mix of all residents. The statewide
					 average case-mix index of all residents, regardless of principal payer on the
					 effective date of the assessment, in a Virginia Medicaid certified nursing
					 facility may be used for case-mix neutralization. The use of the facility
					 average Medicaid case-mix index to adjust the prospective rate would not
					 change.
4. There shall be a
					 correction period for Medicaid-certified nursing facilities to submit
					 correction assessments to the CMS MDS database following each picture date. A
					 report that details the picture date RUG category and CMI score for each
					 resident in each nursing facility shall be mailed to the facility for review.
					 The nursing facility shall have a 30-day time period to submit any correction
					 assessments to the MDS database or to contact the Department of Medical
					 Assistance Services regarding other corrections. Corrections submitted in the
					 30-day timeframe shall be included in the final report of the CMI scores that
					 shall be used in the calculation of the nursing facility ceilings and rates.
					 Any corrections submitted after the 30-day timeframe shall not be included in
					 the final report of the CMI scores that shall be used in the calculation of the
					 nursing facility ceilings and rates.
5. Assessments that cannot be classified to a
					 RUG-III group due to errors shall be assigned the lowest case-mix index
					 score.
6. Assessments shall not be
					 used for any out-of-state nursing facility provider that is enrolled in the
					 Virginia Medical Assistance Program and is required to submit cost reports to
					 the Medicaid program.