Indiana Medicaid Proposes RUGs IV for Nursing Facility Medicaid Rates

Indiana Medicaid and the Division of Aging recently re-opened discussions with the IHCA about transitioning from RUGs III to RUGs IV for purposes of calculating nursing facility Medicaid rates.  Continued use of RUGs III is becoming more complicated for Indiana Medicaid due to waning technical support from CMS on the RUGs III crosswalk and due to the substantial increase in nursing facilities that participate in the UPL program with a county hospital.  Indiana Medicaid’s rate setting contractor, Meyers & Stauffer, indicated that a transition to RUGs IV would spend approximately $22M more on nursing facility rates (based on Nov. 2012 modeling; combined state and federal dollars).  This is due to better recognition of costs due to clinical complexity in RUGs IV.

Meyers & Stauffer is now updating its modeling to determine overall cost to the State for the transition, and is specifically looking at which RUG IV grouper to use.  RUGs IV has three groupers that could be used, one that has 48 groups, one with 57 groups, and another with 66 groups.  Medicare uses the 66 group version, and Meyers & Stauffer is looking at that group and the 48 group version.  They are examining whether the increased number of groups from 48 to 66, which basically comes down to different rehabilitation categories, has a smaller financial impact on either the State or providers.

In order to make the transition, the State will be announcing training for MDS nurses/coordinators that will likely be held in early to mid-April 2014.  Several changes to the Supportive Documentation Guidelines will be made, as well as changes to the Time-Weighted Guidelines.   The State will also provide shadow-rates to each nursing facility throughout 2014 on a quarterly basis to show that provider what their rate would look like under RUGs IV.  This comparison will be critical for providers as they plan their 2015 budgets and operations, especially since the 7/1/15 Medicaid rate uses data from the current cost report period to set that future rate.

Lastly, the State will need to develop a plan on how to pay for the increased expenditure that is likely to result from RUGs IV.  If the expenditure is an additional $22M in state and federal funds, that equates to roughly $7M in state funds that must be found.  There has been some discussion about eliminating the Special Care Unit add-on to help pay for the transition, but IHCA and other trade associations have pressed hard against that idea.  Instead, IHCA has proposed that the State pay for this transition out of the money it keeps from the nursing home Quality Assessment Fee that isn’t spent on nursing facility rates.

IHCA will continue to be engaged in this important issue and keep members updated.

CMS Approves Value Based Purchasing

CMS issued an approval letter dated December 5, 2013 notifying Indiana Medicaid that the Value Based Purchasing (VBP) methodology for nursing facility reimbursement had been approved (click here to read the approval letter).  The newly approved State Plan Amendment will be implemented retroactively to July 1, 2013.  Meyers & Stauffer, Indiana Medicaid’s rate setting contractor, is currently calculating each nursing facilities’ VBP score based upon the prior year cost report and Schedule X of the cost report.  Once calculations are complete, nursing facilities will begin to receive notice of the claims reprocessing process on and after July 1, 2013.  IHCA has asked Indiana Medicaid to be mindful of potential cash-flow issues if claims reprocessing results in significant overpayments (an overpayment because the facility fared worse under the VBP methodology than it did under prior methodology).  In past claims reprocessing events, Indiana Medicaid has been able to stagger implementation to minimize the impact of significant overpayments.

The VBP program has been in the works for 3 years and is now approved.  To read more detail about the VBP program, click here.  Changes to the VBP methodology in the future are likely to include satisfaction survey measures and MDS Quality Metrics, although how to include either of those types of data is not decided.  IHCA continues to engage Indiana Medicaid and the Division of Aging on those issues.  Any future change to the VBP methodology is not expected until July 1, 2015.

CMS QIO Releases Scope of Work

CMS has released the Quality Improvement Organization (QIO) program’s 11th Scope of Work that will start August 2014.  The main changes are outlined below.  Click here for the section pertinent to skilled nursing facilities.  To review the entire QIO scope of work and all documents, click here. 

Skilled Nursing Facility 11th Scope of Work
(Task C.2:  Reducing Healthcare-Acquired Conditions in Nursing Homes section)

• Recruit 75% of SNFs in each state with oversampling of 1 STAR facilities
     o   QIOs must collect from all SNFs
      -Who participate, a signed statement that the nursing home will actively participate in the    Collaborative, including data submission and data sharing.
      -Who elect not to participate, a signed statement that they decline to participate and why.

• The QIN-QIO shall have a targeted focus on
     o   increasing mobility among long-stay residents,
     o   decreasing unnecessary use of antipsychotics in dementia residents,
     o   decreasing potentially avoidable hospitalizations,
     o   decreasing Health Care Acquired Infections (HAIs) such as Methicillin - resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C.Diff), and vaccinations, such as pneumonia and influenza,
     o   decreasing other Healthcare Acquired Conditions (HACs) such as: urinary tract infections, pressure ulcers, physical restraints, and ensuring an “injury and violence free living” environment as noted in the National Prevention Strategy, and
     o   improving resident satisfaction.

• The QIN-QIO’s efforts related to beneficiary satisfaction shall focus on the nursing home systems that impact quality, such as consistent/permanent staff assignment, communications, leadership, regulatory compliance, clinical models, and quality of life indicators.

• The QIN-QIO shall recruit residents/beneficiaries and their family-members for participation as a part of the QIN-QIO’s Peer-Coach activity. In addition, the QIN-QIO shall include residents/beneficiaries and/or family members in at least two quality improvement activities initiated or performed by the QIN-QIO under Task C.2.

• QINs will conduct two collaboratives: NNHQCC Collaborative(s) I and II shall commence in Year 1 and Year 3 of the contract term, respectively, and each Collaborative shall last for 18 months.
     o NNHQCC will use the Quality Assurance & Performance Improvement (QAPI) model as the framework for nursing home quality improvement.
     o QIN-QIO shall recruit nursing homes to act as “Peer-Coaches” for other nursing homes in the Collaboratives if they are a high-performing nursing home, defined as being in the top 10% of the National Nursing Home Composite Quality Measure (to be provided by CMS).
     o QIOs will work to attain a score of six or better on the National Nursing Home Composite Quality Measure (TBD).
     o Improve the rate of mobility among long-stay nursing home residents.
     o Reduce the use of unnecessary antipsychotic medication in dementia residents.

• The QIN-QIO shall create or engage with other Learning Area Networks such as, Advancing Excellence in America’s Nursing Homes Local Area Networks for Excellence (LANEs), Long Term Care Ombudsmen, nursing homes, HHS and CMS agencies, and others committed to nursing home excellence.

CMS Issues Clarified Guidance Related to Jimmo Settlement

In December, CMS issued changes to the Medicare Benefit Policy Manual and held a National Provider call to provide an overview of the program manual changes.  AHCA has provided a brief summary of the Jimmo case as well as an overview of the program manual changes and issues raised on the National Provider call (click here for Member’s Only access to the AHCA memo).  The memo includes web links to pertinent documents, and AHCA will provide a more detailed analysis of the CMS program manual changes in the near future.

CMS Proposed Rule – Disaster Preparedness for all Medicare/Medicaid Providers

On Friday, December 27, CMS issued a proposed rule entitled Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers.  According to CMS (as published in the Federal Register):  This proposed rule would establish national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to ensure that they adequately plan for both natural and man-made disasters, and coordinate with federal, state, tribal, regional, and local emergency preparedness systems. It would also ensure that these providers and suppliers are adequately   prepared to meet the needs of patients, residents, clients, and participants during disasters and emergency situations.
Generally, the proposed standard require providers to develop and maintain: (1) an emergency plan based on a risk assessment and using an all-hazards approach focusing on capacities and capabilities; (2) policies and procedures based on the plan and risk assessment; (3)  a communication plan to coordinate patient care within the facility, across health care providers and with state and local public health departments and emergency systems; and (4) training and testing programs, including initial and annual trainings, conducting drills and exercises or participating in an actual incident that tests the plan. 

Comments on the proposed rule are due on February 25, 2014.  AHCA will be submitting comments to CMS, and if you would like to have your comments/issues/concerns included in ACHA’s comments, please submit them to Lyn Bentley (lbentley@ahca.org) and Peggy Connorton (pconnorton@ahca.org) by February 7.  IHCA will be coordinating its comments with AHCA.

Residential Facility Citation Update

There were 14 offense and deficiency citations issues to residential care facilities in November.  1 of the citations was offense and 13 were deficiency.  Relatively few residential surveys were completed in November as the ISDH survey staff spent more time on nursing facility surveys, catching up from the backlog created by the Federal shutdown in October.  In November, two facilities were cited Tag 36 for not consulting the resident’s physician and legal representative after a significant decline in the residents’ status.  Two facilities were cited Tag 117 for failure to ensure sufficient personnel.  Frequently issued citations, Tag 217 (creation and updating of service plan), Tag 241 (medication administration), Tag 273 (food preparation area sanitation), and Tag 301 (prescription drug labeling) were also cited in November.

Click here to view a summary of the November residential care facility offense and deficiency citations.

ISDH IJ/SSQC Update

There were three events in November 2013 that led to three IJ citations, all of which were also SSQC.  The first facility was cited F309 for the alleged failure of the facility staff to timely initiate CPR on a full-code resident after the resident was found without heartbeat and respirations.  The next facility was cited F323 for alleged failures to maintain safe water temperatures throughout the facility.   The last facility was cited F333 for not cross checking its Medication Administration Record, per its policy and procedures, after the month end change over which led to an incorrect dosage of anticoagulant therapy being administered and resulting in rehospitalization of the resident. 

Click here for a summary of all 2013 IJ/SSQC citations for 2013 and for more detail on the November citations.