AGING AND DISABILITY SERVICES ADMINISTRATION

December 30, 2004

ADSA: NH #2004-037
Resident Assessments and Medicaid Resident Days

Dear Nursing Facility/Home Administrator:

It has come to our attention that some facilities may be under-reporting resident days for Medicaid-eligible patients. This can affect a facility’s Medicaid average case mix index, which is used to calculate the direct care component of the quarterly rate.

Under-reporting of Medicaid resident days generally happens in case where either the eligibility status of the resident is in some doubt or there is a change in eligibility during the resident’s stay in the facility.

To help you report your facility’s Medicaid resident days as accurately as possible, we would like to remind you of several points.

First, if a new resident is a Medicaid client or has made application for Medicaid, a full OBRA (Omnibus Budget Reconciliation Act) initial assessment should be done. Section A Identification and Background Information, Item A7 of the Resident Assessment Instrument (RAI) covers the current payment sources for the resident’s nursing home stay. If the resident has made application for Medicaid coverage and the application is pending, the facility should check the A7a “Medicaid per diem” box.

On the Basic Assessment Tracking Form, Section AA Identification Information, Item AA7 is the “Medicaid No.” This item is to be completed following the RAI User’s Manual guidelines found on page 3-8. The “Medicaid No.” is the 9-digit number entitled “Client ID #” that appears in the footer of an award letter. If an award letter has not been issued and a number has not yet been assigned, indicate that by a “+.” This item should be completed in conjunction with any other assessment information (Medicare, Private, Other) that needs to be completed for the resident as prescribed by RAI rules.

Second, a facility may do an early full quarterly OBRA assessment of a resident when the resident’s payment status changes, to reflect the change from non-Medicaid to Medicaid eligibility. If a facility chooses to do this, it must complete a full OBRA assessment of the resident. The facility should also fill in the Section AA Identification Information, AA7 “Medicaid No.” box. Note that doing an early quarterly assessment will adjust the clinical assessment schedule, since there can be no more than 92 days between the R2b date of one assessment and the R2b date of another assessment. This may result in one extra quarterly assessment being done in a 12 month period, or in an early annual assessment.

Third, the Medicare PPS Assessment Form (MPAF) is used for Medicare-only assessments and does not include information about payer source (A7) or date of admission (AB1). However, the MPAF does include a box – AA7 – for “Medicaid No.” Therefore, if a facility properly uses the MPAF to do a Medicare-only assessment of a resident who is “dual eligible” – i.e., one with Medicare as primary payer source and Medicaid as secondary payer source – and includes the resident’s Medicaid number, the database will pick up that information and will record the resident’s days as Medicaid. The MPAF can be used this way only if the initial entry assessment for the resident was a full OBRA assessment.

Finally, a facility may not selectively assess or report as Medicaid only those residents whose condition might result in an increased case mix index. Rather, a facility must perform assessments for all residents whose Medicaid payment status changes, and should institute written procedures to that effect.

Implementing these steps should improve your reporting of the Medicaid-eligible resident days for your facility.

Sincerely,

Tom Kearns, Chief
Office of Rates Management
Aging and Disability Services Administration