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RI MEDIC
AID
PRIC
ED BASED
PAYM
ENT METH
ODOLOGY
PRESENTE
D BY
MONICA A
. MOTT
A, CPA
RI MEDICAID PRICED-BASED PAYMENT METHODOLOGY
AGENDA
1. Overview of RI Priced Based System
2. Strategic Planning
3. Clinical Planning
4. Financial Planning
NEW CATEGORIES
1. Direct Care–Nursing
2. Direct Care-Other Labor
3. Indirect Care
4. Fair Rental Value
5. Real Estate and Property Taxes
Health Care Provider Assessment
(See handout for “crosswalk”)
NEW CATEGORIES
This chart shows that, on average, 51% of each facility’s average daily Medicaid rate is based on their direct care nursing.
NEW CATEGORIES AVERAGE NURSING HOME PAYMENT
PERCENTAGE
Direct Care-Nursing
$100.44 51.2%
Direct Care – Other
$23.74 12.1%
Indirect Care $53.53 27.3%
Fair Rental Value
$15.69 8.0%
Property Taxes $ 2.60 1.4%
Total $196.00 100.0%
NEW CATEGORIES
Direct Care-Nursing: 101.54% of 2010 statewide
median
Direct Care-Other: 100% of 2010 statewide median
Indirect Care: 93.48% of 2010 statewide median
Fair Rental Value: facility specific
Real Estate and Property Taxes: facility specific
STOP LOSS:DURING PHASE-IN PERIOD 5 YRS
Phase-in period applied to policy adjustors
There are two policy adjustors:
1st policy adjustor - hold harmless for direct care2nd policy adjustor - cannot increase or decrease rate more than $5.00 per day.
STOP LOSS: DURING PHASE-IN PERIOD 5 YRS
Facility
Direct Care
Change
Indirect Care
Change DC Policy
Adjuster
Gain/Loss Policy
Adjuster
Payment Change
A ($20) ($3) $20 $0 ($3)
B ($3) $2 $1 $0 $0
C $2 $7 $0 ($4) $5
D $12 ($1) $0 ($6) $5
E ($20) ($6) $20 $1 ($5)
PHASE IN PERIOD – THROUGH 9/30/2016
Phase in period
10/1/12-9/30/13 – 100% policy adjustor10/1/13-9/30/14 – 75% policy adjustor10/1/14-9/30/15 – 50% policy adjustor10/1/15-9/30/16 – 25% policy adjustorOctober 1, 2016 – Fully phased in
Inflation Factor
GROUPER - HIGHLIGHTS
Rhode Island is using the 48 grouper model
Grouper weights
Rhode Island’s weights for the 48 categories exceed
the national average by approximately 8.4%
We recommend you download the grouper
STRATEGIC PLANNING IDEAS
Gather your management team
Status quo
Target specific residents (be careful)
STRATEGIC PLANNING IDEAS
Number of Bed Facility
Occupancy %
BDP
Medicaid
CMI
Average
Rate
Revenue Medicaid
A 100 92% 33,580 1.00 $207.00 $6,950,000
B 100 89% 32,485 1.05 $216.00 $7,017,000
C 100 89% 32,485 1.10 $211.50 $6,870,000
STRATEGIC PLANNING IDEAS
Business Model Repositioning
Revenue enhancement
Cost containment
Long-Range Planning
Software Upgrades
Physical Upgrades
STRATEGIC PLANNING IDEAS
Whether you choose to do nothing or change your
facility’s focus, the key to success is monitoring … both
clinically and financially.
CLINICAL PLANNING
MDS personnel key
Know weights associated with categories
Quality incentives are coming
Think outside the box
MONITORING, MONITORING, MONITORING
FINANCIAL PLAN
51% of Medicaid rate is based upon the MDS
information and the acuity of resident
49% of Medicaid rate is based upon other factors
Know those factorsCompare your facility to determine financial plans and goals
Every facility is different
Utilize financial tools
OUR COMMITMENT TO YOU
We have developed a RI facility databaseReflects new modelAnnual nursing home analysis
