Statutes, codes, and regulations
Virginia Administrative Code
Title 12 - HEALTHAgency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICESChapter 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CAREPart III - Nursing Home Payment System Appendices
Appendix IV - Resource Utilization Groups (RUGs)
Section 12VAC30-90-306 - Case-mix index (CMI)

12 Va. Admin. Code § 30-90-306

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Current through Register Vol. 41, No. 8, December 2, 2024
Section 12VAC30-90-306 - Case-mix index (CMI)
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.

12 Va. Admin. Code § 30-90-306

Derived from Virginia Register Volume 18, Issue 18, eff. July 1, 2002; Errata, 18:20 VA.R. 2681 June 17, 2002; Amended, Virginia Register Volume 32, Issue 09, eff. 2/11/2016.

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.