471 Neb. Admin. Code, ch. 45, § 016

Current through June 17, 2024

Section 471-45-016 - CLASSIFICATION OF RESIDENTS AND CORRESPONDING WEIGHTS

016.01RESIDENT LEVEL OF CARE. The Department will use a federally approved patient driven payment-model grouper to assign a level of care using the information from the minimum data set. Each level of care will be assigned the federally recommended weight. When no minimum data set assessment is available, the resident will be assigned to a default level of care, Level 280.

016.02WEIGHTING OF RESIDENT DAYS USING RESIDENT LEVEL OF CARE AND WEIGHTS. Each facility resident is assigned to a level of care. Each resident's level of care is appropriately updated from each assessment to the next admission assessment, a significant change assessment, the quarterly review, the annual assessment, etc., and is effective for payment purposes on the first day of the month of the applicable assessment if it is received by the tenth day of the month of the applicable assessment. A change in resident level of care which results from an audit of assessments is retroactive to the effective date of the assessment which is audited. For purposes of the Medicaid case mix system, the Department does not change an assessment record. A record modification may replace an existing record in the Centers for Medicare & Medicaid Services minimum data set data base, but the Department will not replace the existing record in the Medicaid case mix system. The record modification will be processed by the Department as an original record. This means that the Department will process the record in the usual manner if the record is not already in the case mix system. The Department will reject the record as a duplicate if the record has already been accepted into the case mix system. The Department will inactivate a discharge or re-entry tracking record but not an assessment. For each reporting period, the total resident days, per the minimum data set system, at each care level are multiplied by the corresponding weight. The resulting products are summed to determine the total weighted resident days per the minimum data set system. This total is then divided by the minimum data set total resident days per the minimum data set system. This total is then divided by the minimum data set total resident days and multiplied by total resident days per the facility's Medicaid cost report to determine the total number of weighted resident days for the facility, which is the divisor for the direct nursing component.

016.03RESIDENT LEVEL OF CARE WEIGHTS. The following weighting factors must be assigned to each resident level of care, based on the Centers for Medicare and Medicaid Services Patient Driven Payment Model Nursing classifications:

(A) Level of care: 272; Case Mix Group: ES3; Description: Extensive Services 3, Tracheostomy and Ventilator; Case Mix Index Value: 4.06;

(B) Level of care: 271; Case Mix Group: ES2; Description: Extensive Services 2, Tracheostomy or Ventilator; Case Mix Index Value: 3.07;

(C) Level of care: 270; Case Mix Group: ES1; Description: Extensive Services 1, Infection Isolation; Case Mix Index Value: 2.93;

(D) Level of care: 263; Case Mix Group: HDE2; Description: Special Care High, Depressed, Function Score 0-5; Case Mix Index Value: 2.40;

(E) Level of care: 262; Case Mix Group: HDE1; Description: Special Care High, Not Depressed, Function Score 0-5; Case Mix Index Value: 1.99;

(F) Level of care: 261; Case Mix Group: HBC2; Description: Special Care High, Depressed, Function Score 6-14; Case Mix Index Value: 2.24;

(G) Level of care: 260; Case Mix Group: HBC1; Description: Special Care High, Not Depressed, Function Score 6-14; Case Mix Index Value: 1.86;

(H) Level of care: 253; Case Mix Group: LDE2; Description: Special Care Low, Depressed, Function Score 0-5; Case Mix Index Value: 2.08;

(I) Level of care: 252; Case Mix Group: LDE1; Description: Special Care Low, Not Depressed, Function Score 0-5; Case Mix Index Value: 1.73;

(J) Level of care: 251; Case Mix Group: LBC2; Description: Special Care Low, Depressed, Function Score 6-14; Case Mix Index Value: 1.72;

(K) Level of care: 250; Case Mix Group: LBC1; Description: Special Care Low, Not Depressed, Function Score 6-14; Case Mix Index Value: 1.43;

(L) Level of care: 245; Case Mix Group: CDE2; Description: Clinically Complex, Depressed, Function Score 0-5; Case Mix Index Value: 1.87;

(M) Level of care: 244; Case Mix Group: CDE1; Description: Clinically Complex, Not Depressed, Function Score 0-5; Case Mix Index Value: 1.62;

(N) Level of care: 243; Case Mix Group: CBC2; Description: Clinically Complex, Depressed, Function Score 6-14; Case Mix Index Value: 1.55;

(O) Level of care: 241; Case Mix Group: CA2; Description: Clinically Complex, Depressed, Function Score 15-16; Case Mix Index Value: 1.09;

(P) Level of care: 242; Case Mix Group: CBC1; Description: Clinically Complex, Not Depressed, Function Score 6-14; Case Mix Index Value: 1.34;

(Q) Level of care: 240; Case Mix Group: CA1; Description: Clinically Complex, Not Depressed, Function Score 15-16; Case Mix Index Value: 0.94;

(R) Level of care: 221; Case Mix Group: BAB2; Description: Behavior SX Cognition, Restorative Nursing >= 2; Case Mix Index Value: 1.04;

(S) Level of care: 220; Case Mix Group: BAB1; Description: Behavior SX Cognition, Restorative Nursing = 1 or 2; Case Mix Index Value: 0.99;

(T) Level of care: 206; Case Mix Group: PDE2; Description: Reduced Physical Function, Restorative Nursing >= 2, Function Score 0-5; Case Mix Index Value: 1.57;

(U) Level of care: 205; Case Mix Group: PDE1; Description: Reduced Physical Function, Restorative Nursing = 1 or 2, Function Score 0-5; Case Mix Index Value: 1.47;

(V) Level of care: 204; Case Mix Group: PBC2; Description: Reduced Physical Function, Restorative Nursing >= 2, Function Score 6-14; Case Mix Index Value: 1.22;

(W) Level of care: 202; Case Mix Group: PA2; Description: Reduced Physical Function, Restorative Nursing >= 2, Function Score 15-16; Case Mix Index Value: 0.71;

(X) Level of care: 203; Case Mix Group: PBC1; Description: Reduced Physical Function, Restorative Nursing = 1 or 2, Function Score 6-14; Case Mix Index Value: 1.13;

(Y) Level of care: 201; Case Mix Group: PA1; Description: Reduced Physical Function, Restorative Nursing = 1 or 2, Function Score 15-16; Case Mix Index Value: 0.66; or

(Z) Level of care: 280; Casemix Index Vaue: STS; Casemix Index Description: Short-Term Stay; Casemix Index Value: 0.59; Level of Care 280, Short-Term Stay, is used for stays of less than 14 days when a client is discharged and the facility does not complete a full minimum data set admission assessment of the client. This is effective for admissions on or after July 1, 2023.

016.04VERIFICATION. Resident assessment information is audited as a procedure in the Department of Health and Human Services Division of Public Health, Survey and Certification process.

471 Neb. Admin. Code, ch. 45, § 016

Adopted effective 6/6/2022

Amended effective 6/2/2024