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:

• 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.
• 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.
• 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 1^st of the month following the most recent assessment.

• 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.

• 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.

• 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.

• 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.
• 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).
• 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.

For more Information:

• Contact staff at your nursing home.

• Contact the Minnesota Department of Health (MDH) Case Mix Section at 651 215 8703.

• Contact the Office of the Ombudsman for Older Minnesotans at 651 296 0382 or toll free 1 800 657 3591.