On October 1st, 2023, the Massachusetts Department of Health and Human Services will transition from an MMQ Medicaid reimbursement system to a Patient Driven Payment Model (PDPM) Medicaid reimbursement system which is used by the federal government for Medicare Part A reimbursement. The PDPM payment system was originally implemented on October 1, 2019, for Medicare Part A residents in a SNF. Since its inception, certain states also use an iteration of the PDPM model for Medicaid reimbursement in Skilled Nursing Facilities (SNFs).
The PDPM model is designed to reflect the needs of each individual resident more accurately, and to ensure that payment is based on the resident's clinical characteristics and needs, rather than the amount of therapy provided.
Under the Medicare Part A PDPM model, payments to SNFs are based on a resident's classification into one of six components, which are determined by the resident's clinical characteristics and requirements.
Under the PDPM, payments are based on a resident’s classification among 6 components.
1. Physical Therapy Component. There are 16 Case Mix Groups.
2. Occupational Therapy Component. There are 16 Case Mix Groups.
3. Speech-Language Pathology Component. There are 12 Case Mix Groups.
4. Nursing Component. There are 25 Case Mix Groups.
5. Non-Therapy Ancillary (NTA) Component. There are 6 Case Mix Groups.
• A category mostly related to costs associated with drugs and medical supplies.
6. Non-Case Mix Based Rate for Urban/Rural Component. County driven.
Each component has its own payment rate, and the payment rate is adjusted based on various resident characteristics, such as comorbidities and cognitive status. Under the Medicare Part A Reimbursement System, there are approximately over 41,000 different combinations of payment.
Understanding the levels can be overwhelming, however, HHI uses Hopforce PDPM Calculator to educate and train staff on the system. This platform is very helpful when transitioning to a Medicaid PDPM Model.
The PDPM model is intended to incentivize SNFs to provide care that is more tailored to the needs of each resident and is a much better descriptor of the nursing complexities. This goal of the PDPM system is to derive to better outcomes for residents, as well as more efficient use of resources within the Medicaid program.
Although the Medicare Part A PDPM program has six components, most states simply apply the nursing component to the Medicaid reimbursement system. With that said, it is imperative for nursing staff to understand all the elements related to PDPM and the clinical specifics for each level.
If you have questions, please call Kris at 617.595.6032.
Downloads:
