Medicaid PDPM is Coming to Pennsylvania
Pennsylvania has officially proposed the transition date to PDPM-based Medicaid, with the first PDPM CMI picture date set for November 1, 2025.
Key Takeaways of the current proposal:
PDPM Nursing RUG Scores Only: The change will involve PDPM nursing RUG scores exclusively.
Consistent CMI Values: The CMI values assigned to these scores will be the same as those used in Medicare PDPM.
Top-Down Assignment: Similar to Medicare PDPM, the scoring will follow a "top-down" approach, meaning the highest qualifying CMI value may not always be assigned.
Rate Calculations Unchanged: The rate calculation will continue as Base Rate x CMI Value, with adjustments.
o Each Medicaid resident will have only their most recent score assigned for the picture date.
o Current RUGs IV CMI Range: 0.48 to 1.75
o PDPM Nursing CMI Range is higher: 0.62 to 3.84, resulting in higher calculated rates
o The higher calculated rates will be neutralized through a more substantial Budget Adjustment Factor (BAF).
Impact: Patient types, treatments, and accurate assessments will be key drivers of your Medicaid reimbursement under the new system.
The following considerations are not complete lists; just some common examples.
Patient Types That Will Benefit Under PDPM:
Ventilator/Tracheostomy
Comatose
COPD/Shortness of Breath
Patients requiring:
o Daily Respiratory Therapy
o Feeding Tube
o Dialysis
o Supplemental Oxygen
Patients with Parkinson’s, Cerebral Palsy, Multiple Sclerosis
Hemiplegia
Key Treatments and Transient Conditions to Capture When Active under PDPM:
Isolation
IV Fluids
Pneumonia
Wounds
IV Medications
Other impacts
PHQ-9: The capture of depression will have a significant impact on your final rate. A score of 10 or higher is required to trigger for this additional item
Restorative: Restorative programs will be incentivized under the new system, positively impacting residents who do not have significant conditions or treatments such as those mentioned above.
Therapy (PT, OT, SLP)
You will note that there is no mention of therapy. Therapy will no longer have any direct impact on the PDPM nursing score or your Medicaid PDPM CMI. These services will continue to be an important care item and Part B billing will remain unaffected, but they will have no impact to your Medicaid reimbursement.
We will continue to keep you updated as more information becomes available. In the meantime, please monitor your nursing PDPM scores closely and consider how to capture relevant details for residents who are not new admissions.
We will provide you the training and tools that you need to be successful in this significantly changed new system. Stay tuned!