1. A. Definitions

   1. Active Assessment—a resident MDS assessment is considered active when it has been accepted by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS). The assessment will remain active until:

      1. a. a subsequent minimum data set (MDS) assessment for the same resident has been accepted by CMS;
      2. b. the maximum number of days (121) for the assessment has been reached;
      3. c. the record has been replaced by a modified assessment;
      4. d. the record has been inactivated; or
      5. e. the resident has been discharged.
   2. Administrative and Operating Cost Component—the portion of the Medicaid daily rate that is attributable to the general administration and operation of a nursing facility.
   3. Assessment Reference Date—the last day of the MDS observation period, denoted at MDS item A2300. This date is used to determine the due date and delinquency of assessments.
   4. Base Resident-Weighted Median Costs and Prices—the resident-weighted median costs and prices calculated in accordance with §20005 of this rule during rebase years.
   5. Calendar Quarter—a three-month period beginning January 1, April 1, July 1, or October 1.

   6. Capital Cost Component—the portion of the Medicaid daily rate that is:

      1. a. attributable to depreciation;
      2. b. capital related interest;
      3. c. rent; and/or
      4. d. lease and amortization expenses.
   7. Care Related Cost Component—the portion of the Medicaid daily rate that is attributable to those costs indirectly related to providing clinical resident care services to Medicaid recipients.
   8. Case Mix—a measure of the intensity of care and services used by similar residents in a facility.
   9. Case-Mix Documentation Review (CMDR)—a review of original legal medical record documentation and other documentation as designated by the department in the MDS supportive documentation requirements, supplied by a nursing facility provider to support certain reported values that resulted in a specific PDPM classification on a randomly selected MDS assessment sample. The review of the documentation provided by the nursing facility will result in the PDPM classification being supported or unsupported.
   10. Case-Mix Index (CMI)—a numerical value that describes the resident’s resource needs within the groups under the patient driven payment model (PDPM) classification system, prescribed by the department based on the resident’s MDS assessments. CMIs will be determined for each nursing facility on a quarterly basis using all residents.
   11. Case-Mix MDS Documentation Review (CMDR)—a review of original legal medical record documentation on a randomly selected MDS assessment sample. The original legal medical record documentation supplied by the nursing facility is to support certain reported values that resulted in a specific RUG classification. The review of the documentation provided by the nursing facility will result in the RUG classification being supported or unsupported.
   12. Cost Neutralization—refers to the process of removing cost variations associated with different levels of resident case mix. Neutralized cost is determined by dividing a facility’s per diem direct care costs by the facility cost report period case-mix index.
   13. Delinquent MDS Resident Assessment—an active MDS assessment that is more than 121 days old, as measured by the assessment reference date (ARD) field on the MDS, and an MDS assessment that lacks the MDS item responses necessary to calculate a valid PDPM Health Insurance Prospective Payment System (HIPPS) code.
   14. Department—the Louisiana Department of Health (LDH), and the associated work product of its designated contractors and agents.

   15. Direct Care Cost Component—the portion of the Medicaid daily rate that is attributable to:

       1. a. registered nurse (RN), licensed practical nurse (LPN) and nurse aide salaries and wages;
       2. b. a proportionate allocation of allowable employee benefits; and
       3. c. the direct allowable cost of acquiring RN, LPN and nurse aide staff from outside staffing companies.

   16. Final Case-Mix Index Report (FCIR)—the final report that reflects the acuity of the residents in the nursing facility during the reporting period.

       1. a. Prior to the January 1, 2017 rate setting, resident acuity is measured utilizing the point-in-time acuity measurement system.
       2. b. Effective with the January 1, 2017 rate setting, resident acuity will be measured utilizing the time-weighted acuity measurement system.
   17. Index Factor—generated pursuant to 42∙CFR∙413.333.
   18. MDS Supportive Documentation Requirements—the department’s publication of the minimum documentation and review standard requirements for the MDS items associated with the PDPM classification system. These requirements shall be maintained by the department and updated and published as necessary.
   19. Minimum Data Set (MDS)—a core set of screening and assessment data, including common definitions and coding categories that form the foundation of the comprehensive assessment for all residents of long-term care nursing facility providers certified to participate in the Medicaid Program. The items in the MDS standardize communication about resident problems, strengths, and conditions within nursing facility providers, between nursing facility providers, and between nursing facility providers and outside agencies. The Louisiana system will employ the current required MDS assessment as approved by the Centers for Medicare and Medicaid Services (CMS), or as mandated by the Department of Health through the use of the optional state assessment (OSA).

   20. Nursing Facility Cost Report Period Case Mix Index—the average of quarterly nursing facility-wide average case mix indices, carried to four decimal places. The quarters used in this average will be the quarters that most closely coincide with the nursing facility provider’s cost reporting period that is used to determine the medians. This average includes any revisions made due to an on-site CMDR.

       1. a. For the cost reporting periods utilized in the next rebase of rates on or after July 1, 2017, the calendar quarter case mix index averages will be calculated using the time-weighted acuity measurement system, and be inclusive of MDS assessments available as of the date of the applicable quarterly FCIRs. This average includes any revisions made due to an on-site CMDR.

          EXAMPLE: A January 1, 2015-December 31, 2015 cost report period would use the time-weighted facility-wide average case mix indices calculated for the four quarters ending March 31, 2015, June 30, 2015, September 30, 2015 and December 31, 2015.

   21. Nursing Facility-Wide Average Case Mix Index—the simple average, carried to four decimal places, of all resident case mix indices.

       1. a. Prior to the January 1, 2017, rate setting resident case mix indices will be calculated utilizing the point-in-time acuity measurement system. If a nursing facility provider does not have any residents as of the last day of a calendar quarter or the average resident case mix indices appear invalid due to temporary closure or other circumstances, as determined by the department, a statewide average case mix index using occupied and valid statewide nursing facility case mix indices may be used.

          1. i. Effective as of the January 1, 2017 rate setting, resident case mix indices will be calculated utilizing the time-weighted acuity measurement. If a nursing facility provider does not have any residents during the course of a calendar quarter, or the average resident case mix indices appear invalid due to temporary closure or other circumstances, as determined by the department, a statewide average case mix index using occupied and valid statewide nursing facility provider case mix indices may be used.
   22. Optional State Assessment (OSA)—assessment required by the Medicaid program. Allows nursing facility providers using RUG-III models as the basis for Medicaid payment to do so until the legacy payment model (RUG-III) ends.
   23. Pass-Through Cost Componentincludes the cost of property taxes and property insurance. It also includes the provider fee as established by the Department of Health.
   24. Patient Day—a unit of time, a full 24-hour period, during which a Medicaid beneficiary is receiving care in a hospital or skilled nursing facility.

   25. Patient Driven Payment Model (PDPM)—the Medicare payment rule for skilled nursing facilities. The PDPM identifies and adjusts different case-mix components for the varied needs and characteristics of a resident’s care and then combines these with a non-case-mix component to determine the full skilled nursing facilities (SNF) prospective payment system (PPS) per diem rate for that resident.

       1. a. Effective as of the July 1, 2025, rate setting, for Medicaid program nursing facility case-mix index and reimbursement rate calculation purposes, the following PDPM components will be utilized to calculate the nursing facility provider’s total residents average CMI and Medicaid residents average CMI under a blended approach. This is done by using case-mix index weights, effective October 1, 2024, as listed in table 5 from the final SNF PPS payment rule for FY 2025 (CMS-1802-F):

          1. i. physical therapy: 15 percent;
          2. ii. occupational therapy: 15 percent;
          3. iii. speech language pathology: 8 percent;
          4. iv. non-therapy ancillary: 12 percent; and
          5. v. nursing: 50 percent.

   26. Preliminary Case-Mix Index Report (PCIR)—the preliminary report that reflects the acuity of the residents in the nursing facility during the reporting period.

       1. a. Prior to the January 1, 2017 rate setting, resident acuity is measured utilizing the point-in-time acuity measurement system.
       2. b. Effective as of the January 1, 2017 rate setting, resident acuity will be measured utilizing the time-weighted acuity measurement system.

   27. RUG-III Resident Classification System—the resource utilization group used to classify residents. When a resident is sorted into more than one classification group using RUG-III, the RUG-III group with the greatest CMI will be utilized to calculate the nursing facility provider’s total residents average CMI and Medicaid residents average CMI.

       1. a. Effective June 30, 2025, the RUG-III Resident Classification System will no longer be utilized to classify residents except for the purposes of calculating the phase-in as described in §20005.D.4.e.
   28. Rate Year—a one-year period from July 1 through June 30 of the next calendar year during which a particular set of rates are in effect. It corresponds to a state fiscal year.
   29. Resident-Day-Weighted Median Cost—a numerical value determined by arraying the per diem costs and total actual resident days of each nursing facility from low to high and identifying the point in the array at which the cumulative total of all resident days first equals or exceeds half the number of the total resident days for all nursing facilities. The per diem cost at this point is the resident-day-weighted median cost.

   30. Summary Review Results Letter—a letter sent to the nursing facility that reports the final results of the case-mix documentation review and concludes the review.

       1. a. The summary review results letter will be sent to the nursing facility provider within 10 business days after the final exit conference date.
   31. Supervised Automatic Sprinkler System—a system that operates in accordance with the latest adopted edition of the National Fire Protection Association’s Life Safety Code. It is referred to hereafter as a fire sprinkler system.
   32. Time-Weighted Acuity Measurement System (TW)—the case mix index calculation methodology that is compiled from the collection of all resident MDS assessments transmitted and accepted by CMS that are considered active within a given calendar quarter. The resident MDS assessments will be weighted based on the number of calendar days that the assessment is considered an active assessment within a given calendar quarter.
   33. Two-Hour Rated Wall—a wall that meets American Society for Testing and Materials International (ASTM) E119 standards for installation and uses two-hour rated sheetrock.
   34. Unsupported MDS Resident Assessment—an assessment where one or more data items that are used to classify a resident pursuant to the PDPM classification, resident classification systems are not supported according to the MDS supportive documentation requirements and a different PDPM classification, would result; therefore, the MDS assessment would be considered “unsupported.”

2. B. Effective for the rate period of July 1, 2015 through June 30, 2016, the department shall suspend the provisions of LAC 50:II.Chapter 200 governing the reimbursement methodology for nursing facilities and impose the following provisions governing reimbursements for nursing facility services.

   1. 1. During this time period, no inflation factor will be applied to the base resident day weighted medians and prices calculated as of July 1, 2014.
   2. 2. All costs and cost components that are required by rule to be trended forward will only be trended forward to the midpoint of the 2015 state fiscal year (December 31, 2014).
   3. 3. The base capital per square foot value, land value per square foot, and per licensed bed equipment value utilized in the calculation of the fair rental value (FRV) component will be set equal to the value of these items as of July 1, 2014.
   4. 4. Base capital values for the Bed Buy-Back program (§20012) purposes will be set equal to the value of these items as of July 1, 2014.
   5. 5. Nursing facility providers will not have their weighted age totals for the FRV component calculation purposes increased by one year as of July 1, 2015.
   6. 6. As of the July 1, 2016 rate setting, nursing facility provider weighted age totals for the FRV component calculation purposes will be increased by two years to account for the suspended year of aging occurring as of the July 1, 2015 rating period.
   7. 7. No other provisions of LAC 50:II.Chapter 200 shall be suspended for this time period.

3. C. Effective for the rate period of July 1, 2017 through June 30, 2018, the department shall suspend the provisions of LAC 50:II.Chapter 200 governing the reimbursement methodology for nursing facilities and impose the following provisions governing reimbursements for nursing facility services.

   1. 1. During this time period, no inflation factor will be applied to the base resident day weighted medians and prices calculated as of July 1, 2016.
   2. 2. All costs and cost components that are required by rule to be trended forward will only be trended forward to the midpoint of the 2017 state fiscal year (December 31, 2016).
   3. 3. The base capital per square foot value, land value per square foot, and per licensed bed equipment value utilized in the calculation of the fair rental value (FRV) component will be set equal to the value of these items as of July 1, 2016.
   4. 4. Base capital values for the Bed Buy-Back Program (LAC 50:II.20012) purposes will be set equal to the value of these items as of July 1, 2016.
   5. 5. Nursing facility providers will not have their weighted age totals for the FRV component calculation purposes increased by one year as of July 1, 2017.
   6. 6. As of the July 1, 2018 rate setting, nursing facility provider weighted age totals for the FRV component calculation purposes will be increased by two years to account for the suspended year of aging occurring as of the July 1, 2017 rate period.
   7. 7. No other provisions of LAC 50:II.Chapter 200 shall be suspended for this time period.

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254, R.S. 46:2742, and Title XIX of the Social Security Act.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 28:1473 (June 2002), repromulgated LR 28:1790 (August 2002), amended LR 28:2537 (December 2002), LR 32:2262 (December 2006), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:825 (March 2012), amended by the Department of Health, Bureau of Health Services Financing, LR 42:1522 (September 2016), LR 43:525 (March 2017), LR 43:2187 (November 2017), LR 46:695 (May 2020), LR 46:1684 (December 2020), LR 50:219 (February 2024), LR 51:1610 (October 2025).