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Tip Sheets
THE ‘NEW’ CASE MIX
SYSTEM
Case Mix and Your Rights
Case Mix is a classification system that
assigns a daily payment rate to each nursing home resident
in Minnesota. The rates are based on a comprehensive
assessment of individual needs. When you move into a nursing
home, a team of staff gathers detailed information about you
and your needs. This information is recorded on a form
called the Minimum Data Set (MDS). On October 1, 2002 the
information collected on the MDS became the method in
determining your Case Mix Classification.
The MDS assessment is conducted by
qualified clinical staff and utilizes a team approach that
includes the physician’s diagnosis and orders. Staff will
interview you, review your health records, seek staff input
on all shifts and gather information from family members.
Typically, a complete assessment requires several days. Once
the assessment is completed, a registered nurse will review
all entries and submit the MDS form to the Minnesota
Department of Health.
Your individual Case Mix Classification is calculated by
a careful review of the MDS. Several areas are particularly
important:
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How much help you need with activities of daily
living (ADLs). Four areas are evaluated: 1) getting
in and out of bed (bed mobility); 2) moving from place
to place (transferring); 3) your ability to use the
toilet; and, 4) your ability to eat independently.
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Your health diagnosis and the treatments
you need to maintain or improve your health.
Consideration is given to medical treatments,
rehabilitation and therapy services, special care needs
and the complexity of your care needs.
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Your ability to understand and make
decisions, your mood and behavioral
symptoms and your ability to physically function
within the nursing home.
There are a total of 36 Case Mix
Classifications. Each classification has a separate payment
rate. State law requires nursing homes to bill private pay
and Medicaid residents the same rate when the services are
the same at the same nursing home.
There are 34 classifications specifically
related to the MDS assessment. Should your care needs fall
into more than one classification, the nursing home will
bill you at the higher rate. The remaining two
classifications are utilized only in unique circumstances:
1) residents staying less than 14 days may be billed at a
special short stay rate and 2) new residents whose
assessment is not completed and submitted within 14 days may
receive a special low rate on an interim basis.
Good care requires ongoing assessment and
an up-to-date care plan. Residents must be assessed: within
fourteen days of admission; about every six months from the
date of the first assessment; and, one year from the date of
the last full assessment. In addition, you must be assessed
whenever a significant change occurs affecting more than
one area of health and may be initiated by either you or the
nursing home. Payment rate is effective on the date of
admission and on the 1st of the month following
the most recent assessment.
Nursing Home Residents Rights Related to
Your Case Mix Classification
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You have a right to participate in your
assessment and the development of the plan for your care
and treatment. Staff should ask you or your designated
representative about your needs, preferences and choices.
The care plan must reflect your needs and strengths and
respect your dignity, choices and autonomy. If you are not
satisfied with your care or want to make changes to your
care plan, you have the right to request a special care
conference to discuss your needs.
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You have a right to have timely information
about your Case Mix Classification level and payment
rates. The nursing home will send you and/or your
representative a letter stating your classification and
daily payment rate each time an assessment results in a
change in your classification. If there has been a
mistake in the MDS and the facility submits a correction
of the MDS that affects your classification, you have
the right to be notified of changes.
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If you disagree with the Case Mix Classification, you
have a right to request a reconsideration of the
classification within 30 days from the date you receive
the notice of the rate change. It is important to begin
a reconsideration request as soon as possible after
receiving the notice because it takes time to gather all
the documents. You, your family member or your
representative or the nursing home staff may ask for a
reconsideration.
Reconsideration Process
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First, you must ask the nursing home in writing
for three items: 1) the reconsideration form; 2) a copy
of the completed MDS assessment form; and, 3)
documentation from your medical record that supports the
MDS. The nursing home must respond within 3 working
days.
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Next, complete the reconsideration form. Write
a brief explanation on the back of the form why you
disagree with the classification. Send the
reconsideration form with the MDS assessment and medical
documentation to the Minnesota Department of Health
(MDH).
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MDH will make a decision within 15 working days.
The nursing home will be notified within 5 working days
of decision by MDH. The nursing home will notify you or
your representative of decision. The decision of MDH is
final.
The MDH brochure "Minnesota Case
Mix: How Your Nursing Home Charges are Determined" may
be helpful. You can ask the nursing home for a copy. Or you
can locate a copy of the brochure at: http://www.health.state.mn.us/divs/fpc/consinfo.html.
For more Information:
Contact the Minnesota Department of Health (MDH) Case
Mix Section at 651 215 8703.
Contact the Office of the Ombudsman for Older
Minnesotans at 651-431-2555 or toll free 1 800 657 3591.
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