The Family Care MCO rates by RUG category spreadsheets display nursing facility daily rates by RUG-IV (48 cell) category for use by Family Care MCOs. The spreadsheets provide rates by state fiscal year, going back seven years. Each file displays the final July 1 Medicaid fee-for-service (FFS) non-DD rate based on the average FFS Medicaid case mix index (CMI) for each facility. Please note that the FFS rates are updated quarterly based on changes in the average CMI values for each facility, these quarterly updates are not included in the Family Care MCO spreadsheet as they only apply to FFS residents. Effective January 1, 2022, the spreadsheets will provide rates for each PDPM Nursing and NTA category.
The current state fiscal year spreadsheet is updated monthly, around the 1st of each month, until FFS rate setting is complete for that rate year. If you have questions regarding the spreadsheet or rates, please contact your nursing home’s assigned auditor. Contact information for the WI Department of Health Services’ Nursing Home Policy and Rate Setting Section is available here.
Important Updates to the SFY 2022 Family Care MCO Rates Spreadsheet
The Wisconsin Department of Health Services has determined that there is a discrepancy between how the Direct Care – Nursing Allowance and non-Direct Care Allowance values were rounded in the Family Care MCO Rate Spreadsheet (PDPM tab), the provider e-copy rate sheets, and ForwardHealth. For some nursing facilities, this discrepancy means the per diem rate listed on the Family Care MCO Rate spreadsheet (PDPM tab) differed from ForwardHealth by +/- $0.01 or +/- $0.02. The Department has determined that the most appropriate rounding occurred when the rates were added to ForwardHealth. The Direct Care – Nursing Allowance values and non-Direct Care Allowance values have been updated on the Family Care MCO Rates spreadsheet (PDPM tab) and now align with ForwardHealth.
MCOs payment amounts based on values on the Family Care MCO Rate spreadsheet meet contractual requirement VIII. L. 7. c. regarding MCOs reimbursing nursing home services at the Medicaid fee-for-service rates, even if those values differ by +/- $0.01 or $0.02.
The DC – Other Allowance values were already consistent across ForwardHealth, the Family Care MCO Rate spreadsheet, and provider e-copy rate sheets.
Because the Medicaid Hospice rate is a sum of a provider’s non-Direct Care Allowance, PDPM Nursing component, and PDPM Non-Therapy Ancillary (NTA) component, the aforementioned rounding discrepancy means some Medicaid Hospice rates are incorrect in ForwardHealth, on the Family Care MCO Rate spreadsheet (PDPM tab), and on provider e-copy rate sheets (P4-PDPM tab). Some Medicaid Hospice Rates are incorrect by +/- $0.01 or +/- $0.02.
The Medicaid Hospice rates have been updated on the Family Care MCO Rates spreadsheet (PDPM tab) and will be updated in ForwardHealth.
Mid-Fiscal Year Rate Changes on the SFY 2022 Family Care MCO Rates Spreadsheet
The Wisconsin Department of Health Services has determined the SFY 2022 Family Care MCO Rates spreadsheet may not have included all rates for providers who qualified for a Small Facility Incentive during SFY 2022. In some instances, the spreadsheet did not properly convey the rates before and after the incentive was applied, or when the rate change was effective during SFY 2022. The “Summary – SFY22 RUG” tab and the “Summary – SFY22 PDPM” tab spreadsheet have been updated to include the proper rates and rate effective dates.
The spreadsheet now lists the appropriate rates for the following nursing home facilities:
POP ID 143: Northern Lights
POP ID 162: Birch Hill Health Services
POP ID 202: Homestead Health Services
POP ID 214: Wissota Health and Regional Vent Center
POP ID 383: Manor of Fond Du Lac
POP ID 707: Little Chute Health Services
POP ID 716: Ellsworth Health Services
POP ID 731: Portage County Health Care Center
POP ID 732: Prairie Nursing Facility LLC
POP ID 735: Plymouth Health Services
POP ID 764: Stevens Point Health Services
POP ID 818: Williams Bay Health Services
POP ID 861: St. Dominic Village
POP ID 862: Epione Village
POP ID 954: Masonic Center Health & Rehab
ForwardHealth already lists the rates for the correct time periods. These providers and MCOs should review claims for date of service 07/01/2021 forward to determine if services were billed and reimbursed at the appropriate rates.