Ohio Admin. Code 5160-3-43.2 - Nursing facilities (NFs): case mix classification system - resource utilization groups (RUG)
(A)
The Ohio
medicaid case mix payment system for direct care contains the following core
components:
(1)
As set forth in rule
5160-3-43.1 of the
Administrative Code, a uniform resident assessment instrument (minimum data set
version 3.0 (MDS 3.0)), that provides the data used to group residents into
case mix categories. The MDS 3.0 includes section S. Information regarding
section S is available on the ODM website at http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTermCareFacilities.aspx
.
(2)
A methodology for grouping residents into case mix
groups in a way that is clinically meaningful and uses criteria that
sufficiently differentiates one group from another, as provided in paragraphs
(B) to (E) of this rule.
(3)
A means of measuring the relative costliness of caring
for residents in one group versus another, known as "relative resource
weights," as described in paragraph (D) of this rule.
(B)
The
Ohio case mix payment system shall use the following methodologies for grouping
residents:
(1)
For rates paid for services provided before July 1, 2016, resource utilization
groups version III (RUG III) classification system. The RUG III major
categories listed in paragraph (C) of rule this rule are listed in descending
order of hierarchy. Based on the items in the MDS 3.0, if a resident meets the
criteria for placement in more than one group, the resident will be placed in a
group within the highest major category of resident types according to the
hierarchy unless the activities of daily living (ADL) index score is not met
for placement within the highest major category of resident
types.
(2)
For rates paid for services provided July 1, 2016 and
thereafter, resource utilization groups version IV (RUG IV) classification
system. The RUG IV major categories listed in paragraph (C) of this rule are
listed in descending order of hierarchy. Based on the items in the MDS 3.0, if
a resident meets the criteria for placement in more than one group, the
resident will be placed in a group according to the hierarchy.
(3)
ODM will use the
forty-five grouper model with the RUG III methodology.
(4)
ODM will use one
of the following grouper models with the RUG IV methodology:
(a)
Forty-eight
grouper model.
(b)
Fifty-seven grouper model.
(c)
Sixty-six
grouper model.
(C)
The hierarchy of
RUG major categories in descending order is as follows:
(1)
RUG III using
the forty-five grouper model:
(a)
Extensive services.
(b)
Special
rehabilitation.
(c)
Special care.
(d)
Clinically
complex.
(e)
Impaired cognition.
(f)
Behavior
problems.
(g)
Reduced physical function.
(2)
RUG IV using the
forty-eight, fifty-seven, or sixty-six grouper model:
(a)
Rehabilitation
plus extensive services (sixty-six grouper model only).
(b)
Rehabilitation.
(c)
Extensive services.
(d)
Special care
high.
(e)
Special care low.
(f)
Clinically
complex.
(g)
Behavioral symptoms and cognitive
performance.
(h)
Reduced physical function.
(D)
All
MDS 3.0 data elements related to the RUG classification system must be
completed before a resident can be classified. Residents whose MDS 3.0 forms
contain missing or out-of-range responses to data elements used to determine
the RUG classification shall be assigned to the default group. Corrections to
MDS 3.0 data may be made only as described in paragraph (D) of rule
5160-3-43.1 of the
Administrative Code.
(E)
Each of the RUG groups is assigned a relative resource
weight. This weight indicates the relative amount of staff time required on
average for workers in the registered nurse (RN), licensed practical nurse
(LPN), and nurse aide (NA) worker classifications to deliver care to residents
in that RUG group.
(1)
The relative resource weights are calculated as
follows using the average minutes per worker classification per RUG group
provided by the United States department of health and human services (HHS),
and the most recent available three-year averages of RN, LPN, and NA wages in
Ohio medicaid certified NFs as reported in annual medicaid cost reports
submitted by providers to ODM pursuant to section
5165.10 of the Revised
Code.
(a)
By
setting the NA wage weight at one, wage weights for RNs and LPNs are calculated
by dividing the NA wage into the RN or LPN wage.
(b)
To calculate the
total weighted minutes for each RUG group, the wage weight for each worker
classification is multiplied by the average number of minutes that
classification of workers spends caring for a resident in the RUG group, and
then the products for each RUG group are summed.
(c)
Relative
resource weights are calculated by dividing the lowest group's total weighted
minutes into each group's total weighted minutes. Weight calculations are
rounded to the fourth decimal place. The RUG group with the lowest total
weighted minutes receives a relative resource weight of one.
(2)
The
lowest weight for the RUG groups is used as the weight for the default
group.
(3)
Relative resource weights are set forth on the ODM
website at
http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTermCareFacilities.aspx
.
Replaces: 5160-3- 43.2
Notes
Promulgated Under: 119.03
Statutory Authority: 5165.02, 5165.192
Rule Amplifies: 5165.192
Prior Effective Dates: 4/15/93 (Emer.), 7/1/93, 9/30/93 (Emer.), 1/1/94, 7/1/96 (Emer.), 9/1/96, 7/1/98, 7/1/99 (Emer.), 8/12/99, 7/1/02, 7/1/05, 2/2/06, 7/1/06, 10/1/10
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