The Center for Medicare and Medicaid Services (CMS) is ending support for Resource Utilization Groups (RUG)-III and RUG-IV on federally required assessments for patients residing in Nursing Facilities (NF) and Skilled Nursing Facilities (SNF) as of Oct. 1, 2023.
As noted in the 2018 Medicaid Informational Bulletin, additional resources are available for states to continue to use RUGs for another two years after Oct. 1, 2023. States that wish to continue to use RUGs after Oct. 1, 2023, need to implement Optional State Assessments (OSAs) to gather the needed assessment data which will allow the states to calculate a RUGs payment amount for the services provide to all Medicaid beneficiaries.
Effective Oct. 1, 2023, NC Medicaid will require a concurrent OSA be completed, with the same Assessment Reference Date (ARD), on each federally required assessment submitted. This will allow for a RUGs-based case mix score to be calculated and the current RUG-based reimbursement methodology to continue beyond Oct. 1, 2023.
On Oct. 1, 2025, CMS will replace the current case-mix model, RUG-IV with the patient driven payment model (PDPM).
- States will no longer be able to use RUGs and the OSA effective Oct. 1, 2025.
- NC Medicaid has not decided on a transition date from RUGs to PDPM and will inform providers when a decision is made.
- The transition date will be no later than Oct. 1, 2025.
NC Medicaid recommends nursing facilities start reviewing their internal software systems for OSA compatibility prior to Oct. 1, 2023, in preparation for the implementation of the OSA requirement. As a reminder, the purpose of the OSA is to capture RUG-Ill information to continue reimbursement under a RUG-based resident classification system until NC Medicaid has sufficient data and time to model rates for use in the transition to the PDPM resident classification system.
Training on the completion of the OSA will be conducted by the Resident Assessment Coordinator (RAI), NC Division of Health Service Regulations (DHSR). Visit the NC DHSR training page or call the RAI Coordinator, DHSR, Nursing Home Licensure and Certification Section at 919-855-4520 for information regarding training dates and locations.
Training on the Supportive Documentation Guidelines for the OSA will be conducted by Myers and Stauffer, MDS Validation Review Program for NC Medicaid. Contact the Myers and Stauffer Help Desk at nchelpdesk@mslc.com or call 800-763-2278 for information regarding training dates and locations.
Contact
Those with questions regarding the implementation of the OSA may contact Karen Williams at Karen.L.Williams@dhhs.nc.gov or Dean Smith at Dean.A.Smith@dhhs.nc.gov.