DMAS has indicated it will be providing its decision on the approach to Part A crossover claims under the Medicare PDPM. Under PDPM, effective for Medicare services on and after October 1, 2019, the Medicare program will no longer be RUG based, which makes the current crosswalk for the Medicaid RUG and its associated payment rate for each NF untenable.

Medicaid liability for Part A claims for dual eligibles is capped at a “Medicaid allowable” amount. Currently, this amount is determined by a crosswalk from the Medicare RUG to a mapped Medicaid RUG and its associated payment amount for each NF. If the Medicare payment is in excess of the Medicaid RUG amount, the Medicaid program pays $0; if the Medicare amount is below the Medicaid RUG payment, the Medicaid program pays the difference up to the Medicaid payment amount. 

VHCA-VCAL has worked with DMAS on a new, simpler approach whereby DMAS will use a neutral RUG weight of 1.0 to calculate a facility’s Medicaid per diem allowed amount. In other words, each facility will have one “Medicaid allowable” rate (as opposed to 48 rates under the RUG system) against which the Medicare payment amount, regardless of PDPM codes, will be compared. These case mix neutral facility rates are posted on the DMAS’s nursing facility webpage under the “Crossover” column of the nursing facility RUG-adjusted rate sheet. These rates will be recalculated every state fiscal year (SFY) to reflect any normal annual changes. DMAS promises that additional details regarding PDPM will be published in a future Medicaid Bulletin.

If you have any questions or concerns about this approach, please contact Steve Ford.