Revision of the MA Day of Care Definition Posted March 12, 2004

As posted in the PA Bulletin on December 26, 2003, the definition of "MA Day of Care" has been revised for residents participating in the MA program. The revised definition for MA Day of Care is:

A day of care for which one of the following applies:

  1. The Department pays 100% of the MA rate for an MA resident.
  2. The Department and the resident pay 100% of the MA rate for an MA resident.
  3. A Managed Care Organization (MCO) under contract with the Department or an LTCCAP provider that provides managed care to MA residents pays 100% of the negotiated rate or fee for an MA resident's care.
  4. The resident and either an MCO under contract with the Department or LTCCAP provider that provides managed care to an MA resident pays 100% of the negotiated rate or fee for an MA resident's care.
  5. The Department pays for care provided to an MA resident receiving hospice services in a nursing facility.

This revised definition was effective January 1, 2004 and must be used when completing the MA for MA Case-Mix status of residents for the February 1, 2004 CMI Report. Due to this, we are extending the submission deadline for this Picture Date to March 31, 2004. If you have already mailed a signed Certification Page to the state database, you should review the residents listed on the CMI Report. If a resident's MA for MA Case-Mix status is correct in light of the new definition, nothing needs to be done. If a change to the MA status is necessary for a resident, submit an MA Change Tracking form. New CMI Reports will continue to be automatically generated and saved in your facility directory during this extension. The Certification Page Postmark Deadline will be extended to April 7, 2004.

The Resident Data Reporting Manual is being modified to include the revised MA Day of Care definition. Until the new manual is posted, use the following information to determine whether or not a resident is MA for MA Case-Mix.

Evaluating for MA for MA Case-Mix Status

Many factors must be considered in evaluating whether the resident is MA for MA Case-Mix. The facility makes the ultimate decision and reports it accordingly as "yes" or "no" at S1d: "Is the resident Medical Assistance for MA Case-Mix?"

What standards must be met in order to consider a resident MA for MA Case-Mix?

  • Must be a resident of an MA facility.
  • The resident must have a Medical Assistance number from the PA ACCESS card.
  • The resident must have a NF eligibility date from the PA/FS 162 - Notice to Applicant. However, this standard does not have to be met for the first 30 days in a NF by residents served by an MA HMO. See the bullet below.
  • The resident must be physically in the facility or on therapeutic leave (Discharge Tracking forms are not completed for residents on therapeutic leave).
  • Residents served by an MA HMO (either mandatory or voluntary) are considered MA for MA Case-Mix during their first 30 days in the NF even though they do not have a PA/FS 162 with a NF Effective Date. They become MA Pending on Day 31 if a PA/FS 162 has not been received. Residents participating in the HealthChoices program fall into this category.
  • A resident funded through the MA Long Term Care Capitated Assistance Program (LTCCAP) is MA for MA Case-Mix. This is an MA financed program that is handled through a capitated payment system (one negotiated payment to be used to meet all the resident's care needs) rather than through the MA per diem payment system. The LTCCAP provider is responsible to pay all NF bills for the duration of the resident's stay. If the resident is funded through an LTCCAP provider (S1c = 1), he is MA for MA Case-Mix. The LTCCAP provider is responsible to provide the facility with a copy of the resident's PA/FS 162.
  • A resident participating in MA hospice is considered MA for MA Case-Mix.
  • A resident receiving some services from a Medicare hospice but the facility is billing MA for the day of care is considered MA for MA Case-Mix.
  • MA must be paying 100% of the resident's day of care or the day of care is paid partially by MA combined with resident pay and/or third party pay other than Medicare Part A to equal 100%.

Non-MA Status

Some situations disqualify a resident from being considered MA for MA Case-Mix:

  • An MA Pending resident is not MA for MA Case-Mix. MA Pending is the resident's status while the application for MA benefits is in process. The resident may be in the NF for an extended period before the PA/FS 162 - Notice to Applicant is issued by the County Assistance Office (CAO). Until the PA/FS 162 is received from the CAO, the MA Pending resident is not MA for MA Case-Mix.
  • A resident funded through the PDA Waiver who is in the NF for respite care is not MA for MA Case-Mix.
  • A resident funded by an out-of-state MA program is not MA for MA Case-Mix.
  • A resident receiving any payment from Medicare Part A (Medicare per diem) is not MA for MA Case-Mix. This includes residents participating in Medicare Part A hospice where Medicare is paying for the day of care. However, payments may be received from Medicare Part B (ancillaries).
  • A resident for which a provider is not receiving any funds from MA is not MA for MA Case-Mix. Some part of the day of care must be paid by MA. There are infrequent situations where, though the resident has an MA number and MA NF effective date, other sources are paying the total facility bill. If the facility is not billing MA for any part of the day of care, the resident is not MA for MA Case-Mix.
  • A resident who has been discharged (AA8a = 06, 07 or 08) is not MA for MA Case-Mix. For instance, when a Discharge Return Anticipated (AA8a = 07) is completed for a resident going into the hospital, the resident is viewed as non-MA until a Reentry Tracking form or MA Change Tracking form is completed with a status of MA for MA Case-Mix (S1d = 1). When a Discharge Tracking form is submitted, the resident is assumed to be non-MA as of the discharge date (R4) and no additional MA Change Tracking form is required to indicate the non-MA status.
  • A resident whose assessment does not contain a response for S1d or S1d is completed with dashes (-) is not MA for MA Case-Mix.

If you have any questions concerning this bulletin, please contact the Myers and Stauffer Helpdesk at 717-541-5809.