Bill Text: MN SF894 | 2013-2014 | 88th Legislature | Introduced
Bill Title: Health care facilities resident case mix classification provisions modifications
Sponsorship: Bipartisan Bill
Status: (Passed) 2014-03-17 - Secretary of State Chapter 147 03/14/14 [SF894 Detail]
Download: Minnesota-2013-SF894-Introduced.html
1.2relating to health; making changes to resident reimbursement classifications;
1.3amending Minnesota Statutes 2012, section 144.0724.
1.4BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
1.5 Section 1. Minnesota Statutes 2012, section 144.0724, is amended to read:
1.6144.0724 RESIDENT REIMBURSEMENT CLASSIFICATION.
1.7 Subdivision 1. Resident reimbursement case mix classifications. The
1.8commissioner of health shall establish resident reimbursement classifications based
1.9upon the assessments of residents of nursing homes and boarding care homes conducted
1.10under this section and according to section256B.438 . The reimbursement classifications
1.11established under this section shall be implemented after June 30, 2002, but no later
1.12than January 1, 2003.
1.13 Subd. 2. Definitions. For purposes of this section, the following terms have the
1.14meanings given.
1.15(a) "Assessment reference date" or "ARD" means thelast day of the minimum data
1.16set observation period. The date sets the designated endpoint of the common observation
1.17period, and all minimum data set items refer back in time from that point. specific end
1.18point for look-back periods in the MDS assessment process. This look-back period is also
1.19called the observation or assessment period.
1.20(b) "Case mix index" means the weighting factors assigned to theRUG-III or
1.21 RUG-IV classifications.
1.22(c) "Index maximization" means classifying a resident who could be assigned to
1.23more than one category, to the category with the highest case mix index.
2.1(d) "Minimum data set" or "MDS" meansthe assessment instrument a core set
2.2of screening, clinical assessment, and functional status elements, that include common
2.3definitions and coding categories specified by the Centers for Medicare and Medicaid
2.4Services and designated by the Minnesota Department of Health.
2.5(e) "Representative" means a person who is the resident's guardian or conservator,
2.6the person authorized to pay the nursing home expenses of the resident, a representative
2.7of thenursing home ombudsman's Office of Ombudsman for Long-Term Care whose
2.8assistance has been requested, or any other individual designated by the resident.
2.9(f) "Resource utilization groups" or "RUG" means the system for grouping a nursing
2.10facility's residents according to their clinical and functional status identified in data
2.11supplied by the facility's minimum data set.
2.12(g) "Activities of daily living" means grooming, dressing, bathing, transferring,
2.13mobility, positioning, eating, and toileting.
2.14(h) "Nursing facility level of care determination" means the assessment process
2.15that results in a determination of a resident's or prospective resident's need for nursing
2.16facility level of care as established in subdivision 11 for purposes of medical assistance
2.17payment of long-term care services for:
2.18(1) nursing facility services under section256B.434 or
256B.441 ;
2.19(2) elderly waiver services under section256B.0915 ;
2.20(3) CADI and BI waiver services under section256B.49 ; and
2.21(4) state payment of alternative care services under section256B.0913 .
2.22Subd. 3. Resident reimbursement classifications prior to January 1, 2012. (a)
2.23Resident reimbursement classifications shall be based on the minimum data set, version
2.243.0 assessment instrument, or its successor version mandated by the Centers for Medicare
2.25and Medicaid Services that nursing facilities are required to complete for all residents.
2.26Prior to January 1, 2012, the commissioner of health shall establish resident classes
2.27according to the 34 group, resource utilization groups, version III or RUG-III model.
2.28Resident classes must be established based on the individual items on the minimum data
2.29set and must be completed according to the facility manual for case mix classification
2.30issued by the Minnesota Department of Health.
2.31(b) Each resident must be classified based on the information from the minimum
2.32data set according to general domains in clauses (1) to (7):
2.33(1) extensive services where a resident requires intravenous feeding or medications,
2.34suctioning, or tracheostomy care, or is on a ventilator or respirator;
2.35(2) rehabilitation where a resident requires physical, occupational, or speech therapy;
3.1(3) special care where a resident has cerebral palsy; quadriplegia; multiple sclerosis;
3.2pressure ulcers; ulcers; fever with vomiting, weight loss, pneumonia, or dehydration;
3.3surgical wounds with treatment; or tube feeding and aphasia; or is receiving radiation
3.4therapy;
3.5(4) clinically complex status where a resident has tube feeding, burns, coma,
3.6septicemia, pneumonia, internal bleeding, chemotherapy, dialysis, oxygen, transfusions,
3.7foot infections or lesions with treatment, hemiplegia/hemiparesis, physician visits or order
3.8changes, or diabetes with injections and order changes;
3.9(5) impaired cognition where a resident has poor cognitive performance;
3.10(6) behavior problems where a resident exhibits wandering or socially inappropriate
3.11or disruptive behavior, has hallucinations or delusions, is physically or verbally abusive
3.12toward others, or resists care, unless the resident's other condition would place the resident
3.13in other categories; and
3.14(7) reduced physical functioning where a resident has no special clinical conditions.
3.15(c) The commissioner of health shall establish resident classification according to a
3.1634 group model based on the information on the minimum data set and within the general
3.17domains listed in paragraph (b), clauses (1) to (7). Detailed descriptions of each resource
3.18utilization group shall be defined in the facility manual for case mix classification issued
3.19by the Minnesota Department of Health. The 34 groups are described as follows:
3.20(1) SE3: requires four or five extensive services;
3.21(2) SE2: requires two or three extensive services;
3.22(3) SE1: requires one extensive service;
3.23(4) RAD: requires rehabilitation services and is dependent in activity of daily living
3.24(ADL) at a count of 17 or 18;
3.25(5) RAC: requires rehabilitation services and ADL count is 14 to 16;
3.26(6) RAB: requires rehabilitation services and ADL count is ten to 13;
3.27(7) RAA: requires rehabilitation services and ADL count is four to nine;
3.28(8) SSC: requires special care and ADL count is 17 or 18;
3.29(9) SSB: requires special care and ADL count is 15 or 16;
3.30(10) SSA: requires special care and ADL count is seven to 14;
3.31(11) CC2: clinically complex with depression and ADL count is 17 or 18;
3.32(12) CC1: clinically complex with no depression and ADL count is 17 or 18;
3.33(13) CB2: clinically complex with depression and ADL count is 12 to 16;
3.34(14) CB1: clinically complex with no depression and ADL count is 12 to 16;
3.35(15) CA2: clinically complex with depression and ADL count is four to 11;
3.36(16) CA1: clinically complex with no depression and ADL count is four to 11;
4.1(17) IB2: impaired cognition with nursing rehabilitation and ADL count is six to ten;
4.2(18) IB1: impaired cognition with no nursing rehabilitation and ADL count is six
4.3to ten;
4.4(19) IA2: impaired cognition with nursing rehabilitation and ADL count is four or
4.5five;
4.6(20) IA1: impaired cognition with no nursing rehabilitation and ADL count is four
4.7or five;
4.8(21) BB2: behavior problems with nursing rehabilitation and ADL count is six to ten;
4.9(22) BB1: behavior problems with no nursing rehabilitation and ADL count is
4.10six to ten;
4.11(23) BA2: behavior problems with nursing rehabilitation and ADL count is four to
4.12five;
4.13(24) BA1: behavior problems with no nursing rehabilitation and ADL count is
4.14four to five;
4.15(25) PE2: reduced physical functioning with nursing rehabilitation and ADL count
4.16is 16 to 18;
4.17(26) PE1: reduced physical functioning with no nursing rehabilitation and ADL
4.18count is 16 to 18;
4.19(27) PD2: reduced physical functioning with nursing rehabilitation and ADL count
4.20is 11 to 15;
4.21(28) PD1: reduced physical functioning with no nursing rehabilitation and ADL
4.22count is 11 to 15;
4.23(29) PC2: reduced physical functioning with nursing rehabilitation and ADL count
4.24is nine or ten;
4.25(30) PC1: reduced physical functioning with no nursing rehabilitation and ADL
4.26count is nine or ten;
4.27(31) PB2: reduced physical functioning with nursing rehabilitation and ADL count
4.28is six to eight;
4.29(32) PB1: reduced physical functioning with no nursing rehabilitation and ADL
4.30count is six to eight;
4.31(33) PA2: reduced physical functioning with nursing rehabilitation and ADL count
4.32is four or five; and
4.33(34) PA1: reduced physical functioning with no nursing rehabilitation and ADL
4.34count is four or five.
4.35 Subd. 3a. Resident reimbursement classifications beginning January 1, 2012.
4.36(a) Beginning January 1, 2012, resident reimbursement classifications shall be based
5.1on the minimum data set, version 3.0 assessment instrument, or its successor version
5.2mandated by the Centers for Medicare and Medicaid Services that nursing facilities are
5.3required to complete for all residents. The commissioner of health shall establish resident
5.4classes classifications according to the RUG-IV, 48 group, resource utilization groups.
5.5Residentclasses classification must be established based on the individual items on the
5.6minimum data set, which must be completed according to the Long Term Care Facility
5.7Resident Assessment Instrument User's Manual Version 3.0 or its successor issued by the
5.8Centers for Medicare and Medicaid Services.
5.9(b) Each resident must be classified based on the information from the minimum data
5.10set according to generaldomains categories as defined in the Facility Manual for Case Mix
5.11Classification Manual for Nursing Facilities issued by the Minnesota Department of Health.
5.12 Subd. 4. Resident assessment schedule. (a) A facility must conduct and
5.13electronically submit to the commissioner of healthcase mix MDS assessments that
5.14conform with the assessment schedule defined by Code of Federal Regulations, title 42,
5.15section 483.20, and published by the United States Department of Health and Human
5.16Services, Centers for Medicare and Medicaid Services, in the Long Term Care Assessment
5.17Instrument User's Manual, version 3.0, and subsequent updates when issued by the
5.18Centers for Medicare and Medicaid Services. The commissioner of health may substitute
5.19successor manuals or question and answer documents published by the United States
5.20Department of Health and Human Services, Centers for Medicare and Medicaid Services,
5.21to replace or supplement the current version of the manual or document.
5.22(b) The assessments used to determine a case mix classification for reimbursement
5.23include the following:
5.24(1) a new admission assessmentmust be completed by day 14 following admission;
5.25(2) an annual assessment which must have an assessment reference date (ARD)
5.26within 92 days of the previous assessment and within 366 days of the ARD of thelast
5.27 previous comprehensive assessment;
5.28(3) a significant change in status assessment must be completed within 14 days of
5.29the identification of a significant change;and
5.30(4) all quarterly assessments must have an assessment reference date (ARD) within
5.3192 days of the ARD of the previous assessment.;
5.32(5) any significant correction to a prior comprehensive assessment, if the assessment
5.33being corrected is the current one being used for RUG classification; and
5.34(6) any significant correction to a prior quarterly assessment, if the assessment being
5.35corrected is the current one being used for RUG classification.
6.1(c) In addition to the assessments listed in paragraph (b), the assessments used to
6.2determine nursing facility level of care include the following:
6.3(1) preadmission screening completed under section256B.0911, subdivision 4a ,
6.4by a county, tribe, or managed care organization under contract with the Department
6.5of Human Services; and
6.6(2) a face-to-face long-term care consultation assessment completed under section
6.7256B.0911, subdivision 3a
, 3b, or 4d, by a county, tribe, or managed care organization
6.8under contract with the Department of Human Services.
6.9 Subd. 5. Short stays. (a) A facility must submit to the commissioner of health an
6.10initial admission assessment for all residents who stay in the facility less than 14 days or
6.11less.
6.12(b) Notwithstanding the admission assessment requirements of paragraph (a), a
6.13facility may elect to accept a short stay rate with a case mix index of 1.0 for all facility
6.14residents who stayless than 14 days or less in lieu of submitting an initial admission
6.15 assessment. Facilities shall make this election annually.
6.16(c) Nursing facilities must elect one of the options described in paragraphs (a) and
6.17(b) by reporting to the commissioner of health, as prescribed by the commissioner. The
6.18election is effective on July 1 each year.
6.19(d) For residents who are admitted or readmitted and leave the facility on a frequent
6.20basis and for whom readmission is expected, the resident may be discharged on an
6.21extended leave status. This status does not require reassessment each time the resident
6.22returns to the facility unless a significant change in the resident's status has occurred since
6.23the last assessment. The case mix classification for these residents is determined by the
6.24facility election made in paragraphs (a) and (b).
6.25 Subd. 6. Penalties for late or nonsubmission. A facility that fails to complete
6.26or submit an assessment according to subdivisions 4 and 5 for aRUG-III or RUG-IV
6.27classification within seven days of the time requirementsin subdivisions 4 and 5 listed in
6.28the Long-Term Care Facility Resident Assessment Instrument User's Manual is subject to
6.29a reduced rate for that resident. The reduced rate shall be the lowest rate for that facility.
6.30The reduced rate is effective on the day of admission for new admission assessments, on
6.31the ARD for significant change in status assessments, or on the day that the assessment
6.32was due for all other assessments and continues in effect until the first day of the month
6.33following the date of submission and acceptance of the resident's assessment.
6.34 Subd. 7. Notice of resident reimbursement classification. (a) The commissioner
6.35of health shall provide to a nursing facility a notice for each resident of the reimbursement
6.36classification established under subdivision 1. The notice must inform the resident of the
7.1classification that was assigned, the opportunity to review the documentation supporting
7.2the classification, the opportunity to obtain clarification from the commissioner, and the
7.3opportunity to request a reconsideration of the classification and the address and telephone
7.4number of the Office of Ombudsman for Long-Term Care. The commissioner must
7.5transmit the notice of resident classification by electronic means to the nursing facility.
7.6A nursing facility is responsible for the distribution of the notice to each resident, to the
7.7person responsible for the payment of the resident's nursing home expenses, or to another
7.8person designated by the resident. This notice must be distributed within three working
7.9days after the facility's receipt of the electronic file of notice of case mix classifications
7.10from the commissioner of health.
7.11 (b) If a facility submits acorrection modification to the most recent assessment
7.12used to establish a case mix classification conducted under subdivision 3 that results in a
7.13change in case mix classification, the facility shall give written notice to the resident or the
7.14resident's representative about the item that wascorrected modified and the reason for the
7.15correction modification. The notice of corrected modified assessment may be provided
7.16at the same time that the resident or resident's representative is provided the resident's
7.17corrected modified notice of classification.
7.18 Subd. 8. Request for reconsideration of resident classifications. (a) The resident,
7.19or resident's representative, or the nursing facility or boarding care home may request that
7.20the commissioner of health reconsider the assigned reimbursement classification. The
7.21request for reconsideration must be submitted in writing to the commissioner within
7.2230 days of the day the resident or the resident's representative receives the resident
7.23classification notice. The request for reconsideration must include the name of the
7.24resident, the name and address of the facility in which the resident resides, the reasons for
7.25the reconsideration,the requested classification changes, and documentation supporting
7.26therequested classification request. The documentation accompanying the reconsideration
7.27request is limited to documentation which establishes that the needs of the resident at the
7.28time of the assessment justify a classification which is different than the classification
7.29established by the commissioner of health. The documentation accompanying the
7.30reconsideration request is limited to a copy of the MDS that determined the classification
7.31and other documents that would support or change the MDS findings.
7.32(b) Upon request, the nursing facility must give the resident or the resident's
7.33representative a copy of the assessment form and the other documentation that was given
7.34to the commissioner of health to support the assessment findings. The nursing facility
7.35shall also provide access to and a copy of other information from the resident's record that
7.36has been requested by or on behalf of the resident to support a resident's reconsideration
8.1request. A copy of any requested material must be provided within three working days of
8.2receipt of a written request for the information. Notwithstanding any law to the contrary,
8.3the facility may not charge a fee for providing copies of the requested documentation.
8.4If a facility fails to provide the material within this time, it is subject to the issuance
8.5of a correction order and penalty assessment under sections144.653 and
144A.10 .
8.6Notwithstanding those sections, any correction order issued under this subdivision must
8.7require that the nursing facility immediately comply with the request for information and
8.8that as of the date of the issuance of the correction order, the facility shall forfeit to the
8.9state a $100 fine for the first day of noncompliance, and an increase in the $100 fine by
8.10$50 increments for each day the noncompliance continues.
8.11(c) In addition to the information required under paragraphs (a) and (b), a
8.12reconsideration request from a nursing facility must contain the following information: (i)
8.13the date the reimbursement classification notices were received by the facility; (ii) the date
8.14the classification notices were distributed to the resident or the resident's representative;
8.15and (iii) a copy of a notice sent to the resident or to the resident's representative. This
8.16notice must inform the resident or the resident's representative that a reconsideration
8.17of the resident's classification is being requested, the reason for the request, that the
8.18resident's rate will change if the request is approved by the commissioner, the extent of the
8.19change, that copies of the facility's request and supporting documentation are available
8.20for review, and that the resident also has the right to request a reconsideration. If the
8.21facility fails to provide the required information listed in item (iii) with the reconsideration
8.22request, the commissioner may request that the facility provide the information within 14
8.23calendar days. The reconsideration request must be denied if the information is then not
8.24provided, and the facility may not make further reconsideration requests on that specific
8.25reimbursement classification.
8.26(d) Reconsideration by the commissioner must be made by individuals not involved
8.27in reviewing the assessment, audit, or reconsideration that established the disputed
8.28classification. The reconsideration must be based upon theinitial assessment that
8.29determined the classification and upon the information provided to the commissioner
8.30under paragraphs (a) and (b). If necessary for evaluating the reconsideration request, the
8.31commissioner may conduct on-site reviews. Within 15 working days of receiving the
8.32request for reconsideration, the commissioner shall affirm or modify the original resident
8.33classification. The original classification must be modified if the commissioner determines
8.34that the assessment resulting in the classification did not accurately reflectthe needs or
8.35assessment characteristics of the resident at the time of the assessment. The resident and
8.36the nursing facility or boarding care home shall be notified within five working days after
9.1the decision is made. A decision by the commissioner under this subdivision is the final
9.2administrative decision of the agency for the party requesting reconsideration.
9.3(e) The resident classification established by the commissioner shall be the
9.4classification that applies to the resident while the request for reconsideration is pending.
9.5If a request for reconsideration applies to an assessment used to determine nursing facility
9.6level of care under subdivision 4, paragraph (c), the resident shall continue to be eligible
9.7for nursing facility level of care while the request for reconsideration is pending.
9.8(f) The commissioner may request additional documentation regarding a
9.9reconsideration necessary to make an accurate reconsideration determination.
9.10 Subd. 9. Audit authority. (a) The commissioner shall audit the accuracy of resident
9.11assessments performed under section256B.438 through any of the following: desk audits,;
9.12 on-site review of residents and their records,; and interviews with staff and, residents, or
9.13residents' families. The commissioner shall reclassify a resident if the commissioner
9.14determines that the resident was incorrectly classified.
9.15(b) The commissioner is authorized to conduct on-site audits on an unannounced
9.16basis.
9.17(c) A facility must grant the commissioner access to examine the medical records
9.18relating to the resident assessments selected for audit under this subdivision. The
9.19commissioner may also observe and speak to facility staff and residents.
9.20(d) The commissioner shall consider documentation under the time frames for
9.21coding items on the minimum data set as set out in the Long-Term Care Facility Resident
9.22Assessment Instrument User's Manual published by the Centers for Medicare and
9.23Medicaid Services.
9.24(e) The commissioner shall develop an audit selection procedure that includes the
9.25following factors:
9.26(1) The commissioner may target facilities that demonstrate an atypical pattern
9.27of scoring minimum data set items, nonsubmission of assessments, late submission of
9.28assessments, or a previous history of audit changes of greater than 35 percent. The
9.29commissioner shall select at least 20 percent, with a minimum of ten assessments, of the
9.30most current assessments submitted to the state for audit. Audits of assessments selected
9.31in the targeted facilities must focus on the factors leading to the audit. If the number of
9.32targeted assessments selected does not meet the threshold of 20 percent of the facility
9.33residents, then a stratified sample of the remainder of assessments shall be drawn to meet
9.34the quota. If the total change exceeds 35 percent, the commissioner may conduct an
9.35expanded audit up to 100 percent of the remaining current assessments.
10.1(2) Facilities that are not a part of the targeted group shall be placed in a general pool
10.2from which facilities will be selected on a random basis for audit. Every (1) Each facility
10.3shall be audited annually. If a facility has two successive audits in which the percentage of
10.4change is five percent or less and the facility has not been the subject of atargeted special
10.5 audit in the past 36 months, the facility may be audited biannually. A stratified sample of
10.615 percent, with a minimum of ten assessments, of the most current assessments shall be
10.7selected for audit. If more than 20 percent of theRUG-III or RUG-IV classifications after
10.8the audit are changed as a result of the audit, the audit shall be expanded to a second 15
10.9percent sample, with a minimum of ten assessments. If the total change between the first
10.10and second samplesexceed is 35 percent or greater, the commissioner may expand the
10.11audit to all of the remaining assessments.
10.12(3) (2) If a facility qualifies for an expanded audit, the commissioner may audit the
10.13facility again within six months. If a facility has two expanded audits within a 24-month
10.14period, that facility will be audited at least every six months for the next 18 months.
10.15(4) (3) The commissioner may conduct special audits if the commissioner determines
10.16that circumstances exist that could alter or affect the validity of case mix classifications of
10.17residents. These circumstances include, but are not limited to, the following:
10.18(i) frequent changes in the administration or management of the facility;
10.19(ii) an unusually high percentage of residents in a specific case mix classification;
10.20(iii) a high frequency in the number of reconsideration requests received from
10.21a facility;
10.22(iv) frequent adjustments of case mix classifications as the result of reconsiderations
10.23or audits;
10.24(v) a criminal indictment alleging provider fraud;or
10.25(vi) other similar factors that relate to a facility's ability to conduct accurate
10.26assessments.;
10.27(vii) an atypical pattern of scoring minimum data set items;
10.28(viii) nonsubmission of assessments;
10.29(ix) late submission of assessments; or
10.30(x) a previous history of audit changes of 35 percent or greater.
10.31(f) Within 15 working days of completing the audit process, the commissioner shall
10.32make available electronically the results of the audit to the facility. If the results of the
10.33audit reflect a change in the resident's case mix classification, a case mix classification
10.34notice will be made available electronically to the facility, using the procedure in
10.35subdivision 7, paragraph (a). The notice must contain the resident's classification and a
10.36statement informing the resident, the resident's authorized representative, and the facility
11.1of their right to review the commissioner's documents supporting the classification and to
11.2request a reconsideration of the classification. This notice must also include the address
11.3and telephone number of thearea nursing home ombudsman Office of Ombudsman for
11.4Long-Term Care.
11.5 Subd. 10. Transition. After implementation of this section, reconsiderations
11.6requested for classifications made under section144.0722, subdivision 1 , shall be
11.7determined under section144.0722, subdivision 3 .
11.8 Subd. 11. Nursing facility level of care. (a) For purposes of medical assistance
11.9payment of long-term care services, a recipient must be determined, using assessments
11.10defined in subdivision 4, to meet one of the following nursing facility level of care criteria:
11.11 (1) the person requires formal clinical monitoring at least once per day;
11.12 (2) the person needs the assistance of another person or constant supervision to begin
11.13and complete at least four of the following activities of living: bathing, bed mobility,
11.14dressing, eating, grooming, toileting, transferring, and walking;
11.15 (3) the person needs the assistance of another person or constant supervision to begin
11.16and complete toileting, transferring, or positioning and the assistance cannot be scheduled;
11.17 (4) the person has significant difficulty with memory, using information, daily
11.18decision making, or behavioral needs that require intervention;
11.19 (5) the person has had a qualifying nursing facility stay of at least 90 days;
11.20 (6) the person meets the nursing facility level of care criteria determined 90 days
11.21after admission or on the first quarterly assessment after admission, whichever is later; or
11.22 (7) the person is determined to be at risk for nursing facility admission or
11.23readmission through a face-to-face long-term care consultation assessment as specified
11.24in section256B.0911, subdivision 3a , 3b, or 4d, by a county, tribe, or managed care
11.25organization under contract with the Department of Human Services. The person is
11.26considered at risk under this clause if the person currently lives alone or will live alone
11.27upon discharge and also meets one of the following criteria:
11.28 (i) the person has experienced a fall resulting in a fracture;
11.29 (ii) the person has been determined to be at risk of maltreatment or neglect,
11.30including self-neglect; or
11.31 (iii) the person has a sensory impairment that substantially impacts functional ability
11.32and maintenance of a community residence.
11.33 (b) The assessment used to establish medical assistance payment for nursing facility
11.34services must be the most recent assessment performed under subdivision 4, paragraph
11.35(b), that occurred no more than 90 calendar days before the effective date of medical
11.36assistance eligibility for payment of long-term care services. In no case shall medical
12.1assistance payment for long-term care services occur prior to the date of the determination
12.2of nursing facility level of care.
12.3 (c) The assessment used to establish medical assistance payment for long-term care
12.4services provided under sections256B.0915 and
256B.49 and alternative care payment
12.5for services provided under section256B.0913 must be the most recent face-to-face
12.6assessment performed under section256B.0911, subdivision 3a , 3b, or 4d, that occurred
12.7no more than 60 calendar days before the effective date of medical assistance eligibility
12.8for payment of long-term care services.
12.9 Subd. 12. Appeal of nursing facility level of care determination. A resident or
12.10prospective resident whose level of care determination results in a denial of long-term care
12.11services can appeal the determination as outlined in section256B.0911, subdivision 3a ,
12.12paragraph (h), clause (7).
1.3amending Minnesota Statutes 2012, section 144.0724.
1.4BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
1.5 Section 1. Minnesota Statutes 2012, section 144.0724, is amended to read:
1.6144.0724 RESIDENT REIMBURSEMENT CLASSIFICATION.
1.7 Subdivision 1. Resident reimbursement case mix classifications. The
1.8commissioner of health shall establish resident reimbursement classifications based
1.9upon the assessments of residents of nursing homes and boarding care homes conducted
1.10under this section and according to section
1.11
1.12
1.13 Subd. 2. Definitions. For purposes of this section, the following terms have the
1.14meanings given.
1.15(a) "Assessment reference date" or "ARD" means the
1.16
1.17
1.18point for look-back periods in the MDS assessment process. This look-back period is also
1.19called the observation or assessment period.
1.20(b) "Case mix index" means the weighting factors assigned to the
1.21 RUG-IV classifications.
1.22(c) "Index maximization" means classifying a resident who could be assigned to
1.23more than one category, to the category with the highest case mix index.
2.1(d) "Minimum data set" or "MDS" means
2.2of screening, clinical assessment, and functional status elements, that include common
2.3definitions and coding categories specified by the Centers for Medicare and Medicaid
2.4Services and designated by the Minnesota Department of Health.
2.5(e) "Representative" means a person who is the resident's guardian or conservator,
2.6the person authorized to pay the nursing home expenses of the resident, a representative
2.7of the
2.8assistance has been requested, or any other individual designated by the resident.
2.9(f) "Resource utilization groups" or "RUG" means the system for grouping a nursing
2.10facility's residents according to their clinical and functional status identified in data
2.11supplied by the facility's minimum data set.
2.12(g) "Activities of daily living" means grooming, dressing, bathing, transferring,
2.13mobility, positioning, eating, and toileting.
2.14(h) "Nursing facility level of care determination" means the assessment process
2.15that results in a determination of a resident's or prospective resident's need for nursing
2.16facility level of care as established in subdivision 11 for purposes of medical assistance
2.17payment of long-term care services for:
2.18(1) nursing facility services under section
2.19(2) elderly waiver services under section
2.20(3) CADI and BI waiver services under section
2.21(4) state payment of alternative care services under section
2.22
2.23
2.24
2.25
2.26
2.27
2.28
2.29
2.30
2.31
2.32
2.33
2.34
2.35
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
3.12
3.13
3.14
3.15
3.16
3.17
3.18
3.19
3.20
3.21
3.22
3.23
3.24
3.25
3.26
3.27
3.28
3.29
3.30
3.31
3.32
3.33
3.34
3.35
3.36
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12
4.13
4.14
4.15
4.16
4.17
4.18
4.19
4.20
4.21
4.22
4.23
4.24
4.25
4.26
4.27
4.28
4.29
4.30
4.31
4.32
4.33
4.34
4.35 Subd. 3a. Resident reimbursement classifications beginning January 1, 2012.
4.36(a) Beginning January 1, 2012, resident reimbursement classifications shall be based
5.1on the minimum data set, version 3.0 assessment instrument, or its successor version
5.2mandated by the Centers for Medicare and Medicaid Services that nursing facilities are
5.3required to complete for all residents. The commissioner of health shall establish resident
5.4
5.5Resident
5.6minimum data set, which must be completed according to the Long Term Care Facility
5.7Resident Assessment Instrument User's Manual Version 3.0 or its successor issued by the
5.8Centers for Medicare and Medicaid Services.
5.9(b) Each resident must be classified based on the information from the minimum data
5.10set according to general
5.11Classification Manual for Nursing Facilities issued by the Minnesota Department of Health.
5.12 Subd. 4. Resident assessment schedule. (a) A facility must conduct and
5.13electronically submit to the commissioner of health
5.14conform with the assessment schedule defined by Code of Federal Regulations, title 42,
5.15section 483.20, and published by the United States Department of Health and Human
5.16Services, Centers for Medicare and Medicaid Services, in the Long Term Care Assessment
5.17Instrument User's Manual, version 3.0, and subsequent updates when issued by the
5.18Centers for Medicare and Medicaid Services. The commissioner of health may substitute
5.19successor manuals or question and answer documents published by the United States
5.20Department of Health and Human Services, Centers for Medicare and Medicaid Services,
5.21to replace or supplement the current version of the manual or document.
5.22(b) The assessments used to determine a case mix classification for reimbursement
5.23include the following:
5.24(1) a new admission assessment
5.25(2) an annual assessment which must have an assessment reference date (ARD)
5.26within 92 days of the previous assessment and within 366 days of the ARD of the
5.27 previous comprehensive assessment;
5.28(3) a significant change in status assessment must be completed within 14 days of
5.29the identification of a significant change;
5.30(4) all quarterly assessments must have an assessment reference date (ARD) within
5.3192 days of the ARD of the previous assessment
5.32(5) any significant correction to a prior comprehensive assessment, if the assessment
5.33being corrected is the current one being used for RUG classification; and
5.34(6) any significant correction to a prior quarterly assessment, if the assessment being
5.35corrected is the current one being used for RUG classification.
6.1(c) In addition to the assessments listed in paragraph (b), the assessments used to
6.2determine nursing facility level of care include the following:
6.3(1) preadmission screening completed under section
6.4by a county, tribe, or managed care organization under contract with the Department
6.5of Human Services; and
6.6(2) a face-to-face long-term care consultation assessment completed under section
6.8under contract with the Department of Human Services.
6.9 Subd. 5. Short stays. (a) A facility must submit to the commissioner of health an
6.10
6.11less.
6.12(b) Notwithstanding the admission assessment requirements of paragraph (a), a
6.13facility may elect to accept a short stay rate with a case mix index of 1.0 for all facility
6.14residents who stay
6.15 assessment. Facilities shall make this election annually.
6.16(c) Nursing facilities must elect one of the options described in paragraphs (a) and
6.17(b) by reporting to the commissioner of health, as prescribed by the commissioner. The
6.18election is effective on July 1 each year.
6.19
6.20
6.21
6.22
6.23
6.24
6.25 Subd. 6. Penalties for late or nonsubmission. A facility that fails to complete
6.26or submit an assessment according to subdivisions 4 and 5 for a
6.27classification within seven days of the time requirements
6.28the Long-Term Care Facility Resident Assessment Instrument User's Manual is subject to
6.29a reduced rate for that resident. The reduced rate shall be the lowest rate for that facility.
6.30The reduced rate is effective on the day of admission for new admission assessments, on
6.31the ARD for significant change in status assessments, or on the day that the assessment
6.32was due for all other assessments and continues in effect until the first day of the month
6.33following the date of submission and acceptance of the resident's assessment.
6.34 Subd. 7. Notice of resident reimbursement classification. (a) The commissioner
6.35of health shall provide to a nursing facility a notice for each resident of the reimbursement
6.36classification established under subdivision 1. The notice must inform the resident of the
7.1classification that was assigned, the opportunity to review the documentation supporting
7.2the classification, the opportunity to obtain clarification from the commissioner, and the
7.3opportunity to request a reconsideration of the classification and the address and telephone
7.4number of the Office of Ombudsman for Long-Term Care. The commissioner must
7.5transmit the notice of resident classification by electronic means to the nursing facility.
7.6A nursing facility is responsible for the distribution of the notice to each resident, to the
7.7person responsible for the payment of the resident's nursing home expenses, or to another
7.8person designated by the resident. This notice must be distributed within three working
7.9days after the facility's receipt of the electronic file of notice of case mix classifications
7.10from the commissioner of health.
7.11 (b) If a facility submits a
7.12used to establish a case mix classification conducted under subdivision 3 that results in a
7.13change in case mix classification, the facility shall give written notice to the resident or the
7.14resident's representative about the item that was
7.15
7.16at the same time that the resident or resident's representative is provided the resident's
7.17
7.18 Subd. 8. Request for reconsideration of resident classifications. (a) The resident,
7.19or resident's representative, or the nursing facility or boarding care home may request that
7.20the commissioner of health reconsider the assigned reimbursement classification. The
7.21request for reconsideration must be submitted in writing to the commissioner within
7.2230 days of the day the resident or the resident's representative receives the resident
7.23classification notice. The request for reconsideration must include the name of the
7.24resident, the name and address of the facility in which the resident resides, the reasons for
7.25the reconsideration,
7.26the
7.27
7.28
7.29
7.30reconsideration request is limited to a copy of the MDS that determined the classification
7.31and other documents that would support or change the MDS findings.
7.32(b) Upon request, the nursing facility must give the resident or the resident's
7.33representative a copy of the assessment form and the other documentation that was given
7.34to the commissioner of health to support the assessment findings. The nursing facility
7.35shall also provide access to and a copy of other information from the resident's record that
7.36has been requested by or on behalf of the resident to support a resident's reconsideration
8.1request. A copy of any requested material must be provided within three working days of
8.2receipt of a written request for the information. Notwithstanding any law to the contrary,
8.3the facility may not charge a fee for providing copies of the requested documentation.
8.4If a facility fails to provide the material within this time, it is subject to the issuance
8.5of a correction order and penalty assessment under sections
8.6Notwithstanding those sections, any correction order issued under this subdivision must
8.7require that the nursing facility immediately comply with the request for information and
8.8that as of the date of the issuance of the correction order, the facility shall forfeit to the
8.9state a $100 fine for the first day of noncompliance, and an increase in the $100 fine by
8.10$50 increments for each day the noncompliance continues.
8.11(c) In addition to the information required under paragraphs (a) and (b), a
8.12reconsideration request from a nursing facility must contain the following information: (i)
8.13the date the reimbursement classification notices were received by the facility; (ii) the date
8.14the classification notices were distributed to the resident or the resident's representative;
8.15and (iii) a copy of a notice sent to the resident or to the resident's representative. This
8.16notice must inform the resident or the resident's representative that a reconsideration
8.17of the resident's classification is being requested, the reason for the request, that the
8.18resident's rate will change if the request is approved by the commissioner, the extent of the
8.19change, that copies of the facility's request and supporting documentation are available
8.20for review, and that the resident also has the right to request a reconsideration. If the
8.21facility fails to provide the required information listed in item (iii) with the reconsideration
8.22request, the commissioner may request that the facility provide the information within 14
8.23calendar days. The reconsideration request must be denied if the information is then not
8.24provided, and the facility may not make further reconsideration requests on that specific
8.25reimbursement classification.
8.26(d) Reconsideration by the commissioner must be made by individuals not involved
8.27in reviewing the assessment, audit, or reconsideration that established the disputed
8.28classification. The reconsideration must be based upon the
8.29determined the classification and upon the information provided to the commissioner
8.30under paragraphs (a) and (b). If necessary for evaluating the reconsideration request, the
8.31commissioner may conduct on-site reviews. Within 15 working days of receiving the
8.32request for reconsideration, the commissioner shall affirm or modify the original resident
8.33classification. The original classification must be modified if the commissioner determines
8.34that the assessment resulting in the classification did not accurately reflect
8.35
8.36the nursing facility or boarding care home shall be notified within five working days after
9.1the decision is made. A decision by the commissioner under this subdivision is the final
9.2administrative decision of the agency for the party requesting reconsideration.
9.3(e) The resident classification established by the commissioner shall be the
9.4classification that applies to the resident while the request for reconsideration is pending.
9.5If a request for reconsideration applies to an assessment used to determine nursing facility
9.6level of care under subdivision 4, paragraph (c), the resident shall continue to be eligible
9.7for nursing facility level of care while the request for reconsideration is pending.
9.8(f) The commissioner may request additional documentation regarding a
9.9reconsideration necessary to make an accurate reconsideration determination.
9.10 Subd. 9. Audit authority. (a) The commissioner shall audit the accuracy of resident
9.11assessments performed under section
9.12 on-site review of residents and their records
9.13residents' families. The commissioner shall reclassify a resident if the commissioner
9.14determines that the resident was incorrectly classified.
9.15(b) The commissioner is authorized to conduct on-site audits on an unannounced
9.16basis.
9.17(c) A facility must grant the commissioner access to examine the medical records
9.18relating to the resident assessments selected for audit under this subdivision. The
9.19commissioner may also observe and speak to facility staff and residents.
9.20(d) The commissioner shall consider documentation under the time frames for
9.21coding items on the minimum data set as set out in the Long-Term Care Facility Resident
9.22Assessment Instrument User's Manual published by the Centers for Medicare and
9.23Medicaid Services.
9.24(e) The commissioner shall develop an audit selection procedure that includes the
9.25following factors:
9.26
9.27
9.28
9.29
9.30
9.31
9.32
9.33
9.34
9.35
10.1
10.2
10.3shall be audited annually. If a facility has two successive audits in which the percentage of
10.4change is five percent or less and the facility has not been the subject of a
10.5 audit in the past 36 months, the facility may be audited biannually. A stratified sample of
10.615 percent, with a minimum of ten assessments, of the most current assessments shall be
10.7selected for audit. If more than 20 percent of the
10.8
10.9percent sample, with a minimum of ten assessments. If the total change between the first
10.10and second samples
10.11audit to all of the remaining assessments.
10.12
10.13facility again within six months. If a facility has two expanded audits within a 24-month
10.14period, that facility will be audited at least every six months for the next 18 months.
10.15
10.16that circumstances exist that could alter or affect the validity of case mix classifications of
10.17residents. These circumstances include, but are not limited to, the following:
10.18(i) frequent changes in the administration or management of the facility;
10.19(ii) an unusually high percentage of residents in a specific case mix classification;
10.20(iii) a high frequency in the number of reconsideration requests received from
10.21a facility;
10.22(iv) frequent adjustments of case mix classifications as the result of reconsiderations
10.23or audits;
10.24(v) a criminal indictment alleging provider fraud;
10.25(vi) other similar factors that relate to a facility's ability to conduct accurate
10.26assessments
10.27(vii) an atypical pattern of scoring minimum data set items;
10.28(viii) nonsubmission of assessments;
10.29(ix) late submission of assessments; or
10.30(x) a previous history of audit changes of 35 percent or greater.
10.31(f) Within 15 working days of completing the audit process, the commissioner shall
10.32make available electronically the results of the audit to the facility. If the results of the
10.33audit reflect a change in the resident's case mix classification, a case mix classification
10.34notice will be made available electronically to the facility, using the procedure in
10.35subdivision 7, paragraph (a). The notice must contain the resident's classification and a
10.36statement informing the resident, the resident's authorized representative, and the facility
11.1of their right to review the commissioner's documents supporting the classification and to
11.2request a reconsideration of the classification. This notice must also include the address
11.3and telephone number of the
11.4Long-Term Care.
11.5 Subd. 10. Transition. After implementation of this section, reconsiderations
11.6requested for classifications made under section
11.7determined under section
11.8 Subd. 11. Nursing facility level of care. (a) For purposes of medical assistance
11.9payment of long-term care services, a recipient must be determined, using assessments
11.10defined in subdivision 4, to meet one of the following nursing facility level of care criteria:
11.11 (1) the person requires formal clinical monitoring at least once per day;
11.12 (2) the person needs the assistance of another person or constant supervision to begin
11.13and complete at least four of the following activities of living: bathing, bed mobility,
11.14dressing, eating, grooming, toileting, transferring, and walking;
11.15 (3) the person needs the assistance of another person or constant supervision to begin
11.16and complete toileting, transferring, or positioning and the assistance cannot be scheduled;
11.17 (4) the person has significant difficulty with memory, using information, daily
11.18decision making, or behavioral needs that require intervention;
11.19 (5) the person has had a qualifying nursing facility stay of at least 90 days;
11.20 (6) the person meets the nursing facility level of care criteria determined 90 days
11.21after admission or on the first quarterly assessment after admission, whichever is later; or
11.22 (7) the person is determined to be at risk for nursing facility admission or
11.23readmission through a face-to-face long-term care consultation assessment as specified
11.24in section
11.25organization under contract with the Department of Human Services. The person is
11.26considered at risk under this clause if the person currently lives alone or will live alone
11.27upon discharge and also meets one of the following criteria:
11.28 (i) the person has experienced a fall resulting in a fracture;
11.29 (ii) the person has been determined to be at risk of maltreatment or neglect,
11.30including self-neglect; or
11.31 (iii) the person has a sensory impairment that substantially impacts functional ability
11.32and maintenance of a community residence.
11.33 (b) The assessment used to establish medical assistance payment for nursing facility
11.34services must be the most recent assessment performed under subdivision 4, paragraph
11.35(b), that occurred no more than 90 calendar days before the effective date of medical
11.36assistance eligibility for payment of long-term care services. In no case shall medical
12.1assistance payment for long-term care services occur prior to the date of the determination
12.2of nursing facility level of care.
12.3 (c) The assessment used to establish medical assistance payment for long-term care
12.4services provided under sections
12.5for services provided under section
12.6assessment performed under section
12.7no more than 60 calendar days before the effective date of medical assistance eligibility
12.8for payment of long-term care services.
12.9 Subd. 12. Appeal of nursing facility level of care determination. A resident or
12.10prospective resident whose level of care determination results in a denial of long-term care
12.11services can appeal the determination as outlined in section
12.12paragraph (h), clause (7).
