Tag: Medicaid

Categories
Article

Transforming Texas Long-Term Care: The Upcoming PDPM LTC Methodology

Big changes are on the horizon for long-term care in Texas. The Texas Health and Human Services Commission (HHSC) is gearing up to implement a new payment methodology, the Patient Driven Payment Model for Long-Term Care (PDPM LTC), set to take effect on September 1, 2025. This marks a significant shift from the current Resource Utilization Group (RUG-III) model, promising enhanced payment accuracy and a stronger focus on the individual needs of patients.

Why the Change? A Shift Towards Patient-Centric Care

The core objective behind PDPM LTC is to move away from a payment system based solely on the volume of services provided, towards one that prioritizes the unique characteristics and complex needs of each individual patient. This aligns payments more closely with the actual costs of care, particularly for long-stay residents with complex conditions and cognitive impairments.

This Texas-specific version of PDPM is modeled after the framework already implemented in skilled nursing facilities (SNFs). Its development has been a collaborative effort, stemming from an internal HHSC workgroup formed in 2019 and extensive consultation with the Nursing Facility Payment Methodology Advisory Committee (NF-PMAC) since early 2020. In April 2022, the NF-PMAC recommended the Texas-specific PDPM model as the best fit for accurately representing Texas nursing home resident characteristics, care services, and costs. This recommendation ultimately led to a legislative directive in the 2024-25 General Appropriations Act (House Bill 1, Rider 25) formally tasking HHSC with its development and implementation.

How PDPM LTC Works: Key Components

The new PDPM LTC methodology leverages the Minimum Data Set (MDS) version 3.0 as its foundational data source for classifying residents. Unlike RUG-III, which has five rate components with only two case-mix adjusted, PDPM LTC operates with a different structure:

  • Nursing Component: This component aims to quantify the direct care needed by a resident based on their MDS 3.0 assessment data. Residents are classified into one of six nursing groups, ranging from “extensive services” (Group E – for high-acuity needs like tracheostomy or ventilator care) to “reduced physical function” (Group P). It’s important to note that this Texas version includes six nursing groups, not all 25 possible CMS SNF PDPM nursing groups. Section GG items are utilized in the calculation of this component.
  • Non-Therapy Ancillary (NTA) Component: This component captures the medical complexity of residents by identifying specific conditions and services, using a weighted count of comorbidities derived from MDS items. Residents are assigned to one of three NTA groups based on their total NTA score.
  • Case-Mix Index (CMI): The Nursing and NTA components are adjusted by a CMI, a relative value assigned based on assessment data. These CMIs for both components will be directly based on the Skilled Nursing Facility (SNF) Medicare PDPM CMIs from the CMS Final Rule for fiscal year 2024. HHSC will not automatically adjust CMIs when CMS updates them, but will evaluate the impact for legislative consideration.
  • Non-Case-Mix Component: This part of the total reimbursement rate is constant for all residents and is not adjusted by CMI. It covers costs related to dietary services, laundry, housekeeping, general administration, and fixed capital assets. This component will be calculated as a weighted median from the most recently examined cost reports.

Special Considerations and Add-ons

PDPM LTC also includes specific considerations for certain patient populations:

  • Severe Cognitive Impairment (BIMS Add-on): Residents with confirmed severe cognitive impairment, as determined by their Brief Interview for Mental Status (BIMS) score on the MDS, will receive an additional 5% of the highest CMI-adjusted nursing rate.
  • HIV/AIDS Add-on: Mirroring Medicare’s SNF PDPM, residents with a confirmed HIV/AIDS diagnosis will receive an additional 18% of their nursing group’s rate and be assigned to the highest NTA rate. Due to federal and state regulations, this diagnosis cannot be reported on MDS data and must be indicated on the claim using ICD-10 Code B20.
  • Therapy Components: The new methodology does not include payments for physical, occupational, and speech/language therapy (PT/OT/SLP) components in the daily care rates; these will continue to be reimbursed through Nursing Facility Specialized Services.
  • Hospice Care: The proposed methodology does not introduce any changes to reimbursement for hospice care, which will continue at 95% of the total rate per resident’s PDPM LTC group.

In total, the combination of these components allows for 72 possible different reimbursement rates. Additionally, two default groups will be in place for situations where MDS assessments are missing or contain errors, ensuring providers are still reimbursed at a base rate.

Implementation and What Comes Next

HHSC plans a phased implementation, with algorithms for PDPM LTC replacing RUG-III calculations and relevant changes being made to the Long-Term Care Online Portal (LTCOP) and claims system. While Section GG of the MDS will be visible in the LTCOP by August 2024 (nursing facilities have been completing it since November 2022), it will not be used for payment calculations until the September 1, 2025, implementation. The Assessment Reference Date (ARD) of the MDS will continue to guide the calculation of PDPM LTC. Importantly, the Long-Term Care Medicaid Information (LTCMI) will still be required for assessments, though the data collected will not be used in PDPM LTC calculations.

HHSC is committed to providing support and resources for providers during this transition. Webinars like the one held on April 12, 2024, are being recorded and made available online, along with presentation slides and a Frequently Asked Questions (FAQ) document summarizing stakeholder questions and HHSC responses. User guides will be updated, and training materials developed to help providers familiarize themselves with the changes. A PDPM LTC calculation worksheet and a crosswalk for billing under the new payment groupers will also be published closer to implementation.

This significant overhaul represents a move towards a more equitable and accurate payment system in Texas long-term care, aiming to better reflect the diverse and complex needs of its residents. Providers are encouraged to stay informed and utilize the resources provided by HHSC as the implementation date approaches.

Categories
Health Law Highlights

Medicaid Overpayment Audits: What Medical Providers Need to Know

Summary of article from Nelson Mullins, by Gabriel Imperato, Hannah Kays, Melissa Scott:

Medicaid overpayment audits ensure program integrity but can be challenging for medical providers. Auditors review medical records and billing documents, typically involving notification, document submission, preliminary findings, appeals, and final determination. Common audit triggers include high claim volumes, unusual billing patterns, frequent adjustments, specific service types, and high rates of new patient claims. Providers can mitigate risks by maintaining accurate documentation, conducting regular internal audits, training staff, implementing compliance programs, and staying updated on regulations. Legal strategies include timely responses, thorough documentation reviews, expert consultations, and utilizing the appeal process to address discrepancies. Engaging knowledgeable healthcare attorneys can help protect practices and efficiently resolve disputes. Understanding the audit process and adhering to best practices can aid providers in managing Medicaid audits effectively.

Categories
Health Law Highlights

Medicaid: CMS Final Rules Aim to Expand Access, Provide Parity with Commercial Markets

Summary of article from Foley & Lardner LLP, by Anil Shankar:

The Centers for Medicare & Medicaid Services (CMS) introduced two significant updates to its Medicaid regulations on May 10, 2024: the Medicaid Access Rule and the Medicaid Managed Care Rule. These updates aim to enhance and standardize reporting, monitoring, and evaluation of Medicaid services, potentially increasing Medicaid reimbursement. The new rules require states and Medicaid managed care plans to report and analyze payment rates and access to services, and to implement corrective action plans for identified access deficiencies. The Managed Care Rule introduces federal “appointment wait time” standards and allows states to increase Medicaid reimbursement to match commercial plan rates. Lastly, the Access Rule establishes a numerical floor for Medicaid rates and requires at least 80% of Medicaid payments to home and community-based service providers to be spent on direct care workers’ compensation.

Categories
Health Law Highlights

CMS Finalizes Major Reforms to Medicaid, Part 1: Medicaid Access Reg

Summary of article from McDermott+Consulting, by Jeffrey Davis, Kayla Holgash, Katie Waldo:

The Centers for Medicare & Medicaid Services (CMS) has issued two new regulations pertaining to state-operated Medicaid programs, aiming to improve access to care for Medicaid enrollees. A notable policy within the ‘Ensuring Access to Medicaid Services’ regulation specifies that at least 80% of Medicaid fee-for-service (FFS) and managed care payments for home- and community-based services (HCBS) must be allocated towards compensation for direct care workers. The regulation also introduces new definitions, allows for state-specific flexibilities, and outlines reporting requirements for states. Other key provisions include the establishment of a grievance process for beneficiaries, regular review of person-centered service plans, and the creation of a Beneficiary Advisory Council. The regulation will take effect 60 days after publication, but specific provisions have varied effective dates.

Categories
Health Law Highlights

CMS Finalizes its Proposal to Advance Interoperability and Improve Prior Authorization Processes

From Sheppard Mullin Richter & Hampton LLP, by Gianfranco Spinelli and Krysten Thomas:

  • Final Rule Issued by CMS: The Centers for Medicare and Medicaid Services (CMS) issued a final rule titled “CMS Interoperability and Prior Authorization” on January 17, 2024, which aims to advance interoperability and improve prior authorization processes. This rule impacts Medicare Advantage organizations, state Medicaid and CHIP agencies, Medicaid and CHIP managed care plans, and plans on the Affordable Care Act exchanges, as well as MIPS eligible clinicians, and eligible hospitals and critical access hospitals.
  • Patient Access API: The final rule requires Impacted Payers to provide patients access to certain information, including claims, cost sharing data, encounter data, and a set of clinical data accessible via health applications. The implementation of this requirement is set for January 1, 2027, which is a change from the original proposed date of January 1, 2026.
  • Provider Access API and Payer-to-Payer API: The rule mandates Impacted Payers to build and maintain a Provider Access API for data sharing with in-network providers. It also requires a Payer-to-Payer API to ensure patients can maintain continuity of care and have uninterrupted access to their health data. Both these requirements are to be implemented by January 1, 2027.
  • Prior Authorization API and Process Improvements: CMS finalized the proposal to require Impacted Payers to build and maintain a Prior Authorization API, which is to be implemented by January 1, 2027. The rule also shortens the time frames for prior authorization decisions and requires Impacted Payers to provide a specific reason for denied decisions. These requirements are to be complied with by January 1, 2026.
  • Public Reporting and Electronic Prior Authorization Measure: The final rule requires Impacted Payers to publicly report certain prior authorization metrics, with the initial set of metrics to be reported by March 31, 2026. It also mandates MIPS eligible clinicians, eligible hospitals, and CAHs to report the number of prior authorizations for medical items and services requested electronically from a Prior Authorization API.
Categories
Health Law Highlights

CMS Issues Interim Rule in Response to State Medicaid Disenrollment Trend

From Nelson Mullins Riley & Scarborough LLP, by Shane Duer, Knicole Emanuel, Cara Ludwig:

  • The Centers for Medicare & Medicaid Services (CMS) has issued an interim rule in response to the trend of states disenrolling recipients from the Medicaid program.
  • The rule aims to limit the removal of recipients from the program for procedural reasons rather than eligibility considerations.
  • States that fail to comply with the rule may face enforcement actions, including submitting a corrective action plan and paying civil money penalties.
  • The rule also requires states to submit reports on their eligibility redetermination activities, which will be made public.
  • The regulations became effective on December 6, 2023.