The Wisconsin Department of Health Services (DHS) is announcing changes to the patient driven payment model prospective payment system case mix index (PDPM PPS CMI). This implements the parity adjustments from CMS.

DHS shared information during the public meeting held July 24, 2023. Find the meeting agenda, presentation slides, and recording on the Nursing Home Reimbursement webpage.

The parity adjustment is tied to CMS final rule 1765 and results in reduced CMIs for direct care. DHS has increased the nursing services base and other direct care supplies and services base to offset this reduction in CMIs.

The table below summarizes the base rate updates. You can also find this information on the Nursing Home Reimbursement webpage in the first two weeks of August.

This will result in automatic claims reprocessing for fee-for-service (FFS) claims, and mandatory claims reprocessing for MCOs. DHS will manually reprocess impacted FFS hospice claims. The below dates are subject to change in the event of unforeseen circumstances.

Information for state fiscal year (SFY) 23 claims FFS reprocessing

• CMIs effective October 1, 2022, will be posted to ForwardHealth by August 11, 2023.
• Facilities will receive revised SFY23 rate letters sometime after August 9, 2023, which reflects rate revisions due to the above base rate updates.
  • There is no rate review period for the October 1, 2022, rates. No provider action is needed in WINHRS.
• Net payment differences for all facilities due to October 1, 2022, rate changes should pay out August 21, 2023.
• An informational banner message will appear on NF, hospice, and ICF facility remits. DHS will remove the banner message on August 20, 2023.
• DHS will provide this information to MCOs.

Information for SFY24 claims processing

• DHS will post interim rates for SFY24 for all facilities and all rate types to both the ForwardHealth Portal and the MCO website. This means interim rates will be set for case-mix-neutral base rates, developmental disability (DD) in-house, DD bedhold, non-DD bedhold, and hospice. These interim rates will reflect SFY24 rate updates as mentioned during the public meeting.
• There is no rate review period for SFY24 interim rates. No provider action is needed in WINHRS.
• There is no rate review period for the October 1, 2023, rates. No provider action is needed in WINHRS.
• DHS will post final rates for SFY24 for Vent, TBI, SPRS to the ForwardHealth Portal.
• The way DHS sets interim rates will not generate a rate letter for facilities. Facilities may refer to the MCO website or the interactive fee schedule for their interim rates.
  • The interim rate shown in either of these sources must be used by providers as appropriate (for example, MCOs and hospice providers). If a payor does not respect the posted rate and requests a rate letter, email DHSDMSBRS@dhs.wisconsin.gov with your POP ID and a summary of the situation.
• DHS will post CMIs effective October 1, 2023, to the ForwardHealth Portal by August 11, 2023.
  • This means claims for SFY24 will have different CMIs already available for July 1, 2023-September 30, 2023, and October 1, 2023 onward.

Please visit the Nursing Home Reimbursement webpage for this information. Please email DHSDMSBRS@dhs.wisconsin.gov if you have questions.