| (a) Introduction. The Texas Health and Human Services
Commission (HHSC) establishes the Patient Driven Payment Model (PDPM)
for Long-Term Care (LTC) described in this section to reimburse nursing
facilities on or after September 1, 2025. The PDPM LTC methodology
will be implemented pending necessary system modifications.
(b) Definitions. The following words and terms, when
used in this section, have the following meanings unless the context
clearly indicates otherwise.
(1) Brief interview for mental status (BIMS)--BIMS
is a mandatory tool used to screen and identify the cognitive condition
of residents upon admission into a nursing facility. BIMS is a part
of minimum data set (MDS) assessment data. It is used to determine
if a resident has a severe cognitive impairment, which necessitates
additional reimbursement under the PDPM LTC classification system.
(2) Case-mix classifiers--These classifiers are codes
based on MDS assessment data used to differentiate between case-mix
index (CMI)-adjusted groups for the nursing and non-therapy ancillary
(NTA) rate components.
(3) Case-mix index (CMI)--CMI is a relative value based
on assessment data used to assign nursing facility residents to a
diagnosis-related group for CMI-adjusted rate components.
(4) Minimum data set (MDS) assessment data--MDS is
clinical assessment data collected by Medicare and Medicaid-certified
nursing facilities as a part of a federally mandated process. MDS
assessment data provide a comprehensive evaluation of each resident's
functional capabilities, comorbidities, and health conditions and
are used to determine case-mix classifiers and PDPM LTC groups.
(5) Patient Driven Payment Model (PDPM) Long-Term Care
(LTC) classification system--This classification system is used to
classify Medicaid recipients who reside in a nursing facility into
1 of 36 PDPM LTC groups based on MDS assessment data. If MDS assessment
data is unavailable or invalid, a resident is assigned to 1 of 2 default
groups.
(6) Patient Driven Payment Model (PDPM) Long-Term Care
(LTC) default group--A default group assigns a temporary classification
when MDS assessment data is incomplete or in error or when an MDS
assessment is missing.
(7) Patient Driven Payment Model (PDPM) Long-Term Care
(LTC) group--Each group represents a unique combination, including
a nursing case-mix classifier, an NTA case-mix classifier, and a BIMS
classification. PDPM LTC groups are used to calculate total per diem
rates under the PDPM LTC classification system.
(c) PDPM LTC classification. HHSC reimbursement rates
for nursing facilities vary according to the assessed characteristics
of Medicaid recipients based on MDS assessment data.
(1) In each of the PDPM LTC groups, nursing facility
residents are classified according to one of six nursing case-mix
classifiers; one of three NTA case-mix classifiers; and a BIMS classification,
which indicates if a resident has severe cognitive impairment. For
the case-mix adjusted rate components, the CMI is assigned based on
relevant MDS assessment data. The nursing and NTA case-mix classifiers
and the BIMS classification are described below.
(A) Nursing case-mix classifiers. A resident is assigned
to one of six nursing case-mix classifications based on their level
of acuity and the level of nursing care needed to address their health
conditions effectively.
(B) NTA case-mix classifiers. A resident is assigned
one of three NTA case-mix classifications based on the presence of
certain conditions or the need for certain extensive services found
to be correlated with increases in NTA costs.
(C) BIMS classification. A resident is assigned as
qualifying for additional BIMS reimbursement if MDS assessment data
indicates a severe cognitive impairment.
(2) PDPM LTC default groups are assigned using the
lowest CMI among nursing case-mix classifiers, the lowest CMI among
NTA case-mix classifiers, and without a BIMS classification of severe
cognitive impairment. Both default groups will be reimbursed at the
same total rate.
(d) PDPM LTC rate components. Total per diem PDPM LTC
rates consist of the following four rate components. Costs used in
HHSC's determination of the following rate components are subject
to the cost-finding methodology as specified in subsection (g) of
this section.
(1) Nursing rate component. This rate component includes
compensation costs for employee and contract labor Registered Nurses
(RNs), including Directors of Nursing (DONs) and Assistant Directors
of Nursing (ADONs); Licensed Vocational Nurses (LVNs), including DONs
and ADONs; medication aides; restorative aides; nurse aides performing
nursing-related duties for Medicaid contracted beds; certified social
worker and social service assistant wages; and other direct care non-professional
staff wages, including medical records staff compensation and benefits.
(A) Compensation to be included for these employee
staff types is the allowable compensation defined in §355.103(b)(1)
of this chapter (relating to Specifications for Allowable and Unallowable
Costs) that is reported as either wages (including payroll taxes and
workers' compensation) or employee benefits. Benefits required by §355.103(b)(1)(A)(iii)
of this chapter to be reported as costs applicable to specific cost
report line items are not to be included in this cost center.
(B) Nursing staff who also have administrative duties
not related to nursing must properly direct charge their compensation
to each type of function performed based on daily time sheets maintained
throughout the entire reporting period.
(C) Nurse aides must meet the qualifications specified
under 26 TAC §556.3 (relating to Nurse Aide Training and Competency
Evaluation Program (NATCEP) Requirements) to be included in this rate
component. Nurse aides include certified nurse aides and nurse aides
in training.
(D) Contract labor refers to personnel for whom the
contracted provider is not responsible for the payment of payroll
taxes (such as federal payroll tax, Medicare, and federal and state
unemployment insurance) and who perform tasks routinely performed
by employees. Allowable contract labor costs are defined in §355.103(b)(3)
of this chapter.
(E) For facilities providing care to children with
tracheostomies requiring daily care as described in §355.307(b)(3)(G)
of this chapter (relating to Reimbursement Setting Methodology before
September 1, 2025), staff required by 26 TAC §554.901(15)(C)(iii)
(relating to Quality of Care) performing nursing-related duties for
Medicaid contracted beds are included in the nursing rate component.
(F) For facilities providing care for qualifying ventilator-dependent
residents as described in §355.307(b)(3)(F) of this chapter,
Registered Respiratory Therapists and Certified Respiratory Therapy
Technicians are included in the nursing rate component.
(G) Nursing facility administrators and assistant administrators
are not included in the nursing rate component.
(H) Staff members performing more than one function
in a facility without a differential in pay between functions are
categorized at the highest level of licensure or certification they
possess. If this highest level of licensure or certification is not
that of an RN, LVN, medication aide, restorative aide, or certified
nurse aide, the staff member is not to be included in the nursing
rate component but rather in the rate component where staff members
with that licensure or certification status are typically reported.
(I) Paid feeding assistants are not included in the
nursing rate component. Paid feeding assistants are intended to supplement
certified nurse aides, not to be a substitute for certified or licensed
nursing staff.
(2) NTA rate component. This rate component includes
costs of providing care to residents with certain comorbidities or
the use of certain extensive services. This rate component includes
central supply costs, including central supply staff compensation
and benefits; ancillary costs, including ancillary staff compensation
and benefits; diagnostic laboratory and radiology costs; durable medical
equipment purchase, rent, or lease costs; oxygen costs; drugs and
pharmaceuticals; therapy consultant costs; and other ancillary supplies
and services purchased by a nursing facility.
(3) BIMS rate component. This rate component includes
additional staff costs associated with providing care to residents
with severe cognitive impairment.
(4) Non-Case-Mix rate component. The Non-Case-Mix rate
component includes the following cost areas.
(A) Dietary costs, including food service and nutritionist
staff expenses and supplies.
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