Medicaid reimbursement questions

Specialties MDS


I am a new MDS nurse and I have a couple questions regarding medicaid reimbursement. I just received our quarterly reimbursment rate information and the CMI is sig lower than the previous quarter. (0.91 now compared to 0.97 on previous quarter). I am trying to better understand how these numbers are figured. Thus the questions:

1) If a medicaid patient is skilled during the entire 3 month window, are they omitted from the medicaid census for that quarter as far as figuring medicaid CMI goes?

2) What if a patient has more than one assessment in a 3 month quarter? Which CMI is used in figuring the reimbursement? Both, Average of two, most recent, or other?

Specializes in ER CCU MICU SICU LTC/SNF.

Only the most recent OBRA-required MDS (stand-alone or combined) is captured in the Medicaid case mix.

Your state MDS RAI Coordinator or Automation Coordinator (first choice) or state Medicaid agency (second choice) should be able to tell you exactly which CMI set is being used for Medicaid payment. Those same people can help you understand why you are getting the RUG/CMI that you are getting if you do not understand why a resident is getting a certain RUG/CMI. Always keep in mind whether or not your state Medicaid uses Index Maximizing for Medicaid RUG calculations.

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