Residential Care and Assisted Living Compendium: 2007. Rates Based on Case-Mix Systems

11/30/2007

Several states have adopted payment systems based on their nursing home case-mix methodology. Like tiered rate approaches, the case-mix approach creates incentives to serve more impaired residents by linking reimbursement to the LOC needed. Case-mix approaches typically have more categories that tiered rates. The case-mix approach requires the collection of extensive functional and health data for residents.

Both tiered rates and case-mix rates are subject to “category creep” or “gaming,” a tendency for facilities to interpret assessment data to support payment of the next higher rate or to request an adjustment because the resident has become more impaired and requires more staff support than upon admission. To address “gaming,” states may use an assessment by an independent case management agency to determine the original payment level. Subsequent requests to adjust the payment level can be reviewed by either a case management agency or the state agency before being approved. Five states use case-mix rates, examples of which are described below.

  • Washington uses a 12-payment level rate structure for waiver services provided in homes and residential care settings. A case manager conducts a comprehensive assessment to measure level of need and the appropriate rate tier. Three sections of the assessment are used to set the payment level based on a combined score based on points for: health status, psychological/social/ cognitive status, and functional abilities and supports. Individuals must have substantial or total impairments in an ADL for it to receive points. Points are also assigned for impairments in speech, sight, and hearing, the number of medications, disorientation, memory impairment, impaired judgment, wandering, and disruptive behavior. The total score determines the payment level.

  • New York modeled its reimbursement rates on its case-mix system for paying nursing homes. The service reimbursement is set at 50 percent of the Resource Utilization Group (RUG) rate for nursing home residents. The state has created RUG rates for 16 geographic areas of the state. The reimbursement category is determined through a joint assessment by the ALP and the designated home health agency or long-term home health care program. The Department of Social Services’ district office reviews the assessment and the RUG category. In 2007, the combined SSI and state supplement payment was $1,264. Beneficiaries retain a PNA of $200 and the balance is paid to the facility for room and board.

  • North Carolina covers personal care in adult care homes as a Medicaid state plan service and uses a modified case-mix payment system. The payment includes a flat rate for basic personal care with add-ons for residents with specific ADL impairments. Residents with extensive or total impairments in eating, toileting, or both eating and toileting qualify for a higher rate. In 2007, the basic payment is $17.33 for facilities with 30 or fewer beds and $18.98 for facilities with more than 30 beds. The additional daily rate for residents with extensive or total impairments in eating is $10.69, toileting $3.82, and impairments in both eating and toileting are reimbursed at $14.51. An additional payment for residents needing assistance with ambulation/locomotion is $2.73 a day. These payment levels are in addition to the basic rate. Eligibility for the additional payment is based on an assessment by the adult care home, which is verified by a county case manager. The state SSI and state supplement payment combined is $1,148 for room and board. The resident keeps $65 a month for personal needs and pays the remaining $1,083 to the facilities for room and board.

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