The potential importance of your final Case Mix rate

Authored by Mark Baron

Community HealthChoices (CHC), Pennsylvania’s program for Medicaid Managed Long-Term Services and Supports (MLTSS), is set to roll out in the state’s Southwest region beginning in January 2018. Following that date, the next phase will cover the Southeast region with implementation beginning in July 2018. The third and final implementation phase will include the Northwest, Northeast and Lehigh/Capital regions and begin in January 2019. 

The Medicaid Case Mix rate for the final quarter preceding the implementation of CHC may be an important rate for all Pennsylvania nursing facilities.

For example, New Jersey used the Case Mix rate for the final quarter preceding the implementation of Medicaid MLTSS to set the “floor” for negotiated managed care rates and to be the go-forward rate paid for residents admitted to nursing facilities prior to the implementation of Medicaid MLTSS. New Jersey’s MLTSS program started in July 2014 and as of January 2017, more than 50 percent of the state’s Medicaid population consisted of residents who were admitted to nursing facilities prior to July 2014. Therefore, nursing facilities continue to be reimbursed at the pre-MLTSS Case Mix rates (as adjusted) for these residents.

Pennsylvania’s CHC implementation dates have already been delayed twice. However, if the Department of Human Services (DHS) follows its current schedule, the final Case Mix quarter for the Southwest region will begin on October 1, 2017, which will utilize the May 1, 2017 picture date to set rates. The Southeast region’s July 2018 rollout means the last Case Mix quarter will begin on April 1, 2018 and use the November 1, 2017 picture date. The remaining regions’ January 2019 implementation date means the last Case Mix quarter will begin on October 1, 2018 and use the May 1, 2018 picture date.

There is no guarantee Pennsylvania will follow the methodology used by New Jersey for its Case Mix to managed care transition payment rates. In fact, it appears unlikely at this point. However, there are no negative implications from planning as though Pennsylvania will transition from fee-for-service to CHC the same way.

For more information on this topic, or to learn how Baker Tilly healthcare specialists can help, contact our team.