DOH Clarifies CMI Constraint Calculations

Nursing home case mix is collected twice per year- in January and July. The Case Mix Index (CMI) of homes whose CMI increases by more than five percent during a six month period is capped at five percent pending audit. If the facility is not selected for audit or if the audit supports the reported increase, the constraint is lifted. If the audit does not support what a home reported, the CMI is recalculated and the Medicaid rate is adjusted.

We had requested clarification on how DOH would calculate CMI growth when audits were lagging by more than a year. The delay required case mix growth to be calculated before the constraint based on previous cycles was resolved. DOH provided this clarification along with sample scenarios of how the constraint would be handled. Prior to audit, DOH will apply the five percent constraint on each cycle starting with the 1/1/12 CMI as the base. After audit or release of the constraint, the audited or released CMI becomes the baseline from which the contraint is calculated.

Although the case mix adjustment is applied to the entire amount in the scenarios, when rates are calculated the CMI impacts only the direct component of the rate.

Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841