Medicaid Nursing Home Reimbursement

Overview

Nursing Facility Information
The Office of Reimbursement and Certificate of Need (CON) is responsible for establishing Medicaid reimbursement methodologies for Medicaid nursing homes. Reimbursement and CON is responsible for Medicaid State Plan Amendments that are necessary to obtain Federal matching funds for nursing home services provided through Connecticut's Medicaid program. There are currently 209 nursing homes and 24,522 licensed beds in Connecticut. Medicaid is the funding source for approximately 74% of nursing home care in Connecticut.
Direct Care - Special Notice to Nursing Homes In accordance with CGS §17b-340, the Department may adjust nursing home Medicaid rates if changes in federal or state laws result in increased costs or expenditures in an amount exceeding one-half of one per cent of allowable costs for the most recent cost reporting year. The Department shall adjust rates and provide payment for any such reasonable increased costs or expenditures within a reasonable period of time retroactive to the date of enforcement. On November 21, 2022, the Department of Public Health amended Section 19-13-D8t of the regulations of Connecticut General Statutes requiring nursing homes to implement a minimum direct care staffing level of three hours of direct care per resident per day. Therefore, the date of enforcement for rate adjustment purposes will be November 21, 2022.

To assist homes with cost increases associated with meeting the minimum staffing requirement, nursing homes may provide information to the Department for rate consideration. Please complete the Direct Care Application form below. Applications will be reviewed by the Department on a rolling basis, and approved rate increases will be issued quarterly. Rates will be adjusted to the date that the costs were incurred but no further than the effective date of the enforcement.

Please complete and submit the Direct Care Application to con-ratesetting.dss@ct.gov

Direct Care Application Form 

Transition to Acuity-Based Methodology for Medicaid Reimbursement of Nursing Facilities
The Connecticut Department of Social Services transitioned Medicaid nursing facility reimbursement on July 1, 2022 from a cost-based methodology to a prospective acuity-based or case mix payment system. This method will aid DSS in its goals of moving toward a system that is data driven, improves transparency, and benefits patient outcomes. View the Acuity Based Methodology webpage for additional information and updates.

Nursing Home Bed Reduction Process The Department is responsible for the Certificate of Need (CON) process for nursing homes. A Nursing Home, or Applicant, may request a decrease in total bed capacity by submitting a letter of Intent for a Certificate of Need (CON) to the Commissioner of the Department of Social Services. Bed Reduction Information

Connecticut Nursing Facility Payer Mix
Under the Connecticut Medicaid program, payment rates for nursing homes are set on a cost-based prospective basis in accordance with Section 17b-340 of the Connecticut General Statutes and Section 17-311-52 of the Regulations of Connecticut State Agencies. The federal government provides states discretion in determining the method used to pay for nursing facility services. The state's reimbursement methodology, however, must be approved by the Centers for Medicare and Medicaid Services (CMS) within the federal Department of Health and Human Services. The annual rate period for nursing homes is July 1 through June 30, unless modified by the legislature. The cost reporting period, however, is October 1 through September 30. Every Medicaid nursing home must complete an "Annual Report of Long-Term Care Facility" which is annually due before February 15th.
Payor Mix  2018  2019  2020
Medicaid  73.91% 74.09%  72.60%
Medicare  11.5% 10.25%  12.08%
Private Pay  9.99% 9.94% 9.97% 
Other (Veterans/Medicaid Other States)  4.6% 5.72%  5.35%

Medicaid State Plan Amendments
The state plan is an agreement between a state and the Federal government describing how that state administers its Medicaid and CHIP programs. It gives an assurance that a state will abide by Federal rules and may claim Federal matching funds for its program activities. The state plan sets out groups of individuals to be covered, services to be provided, methodologies for providers to be reimbursed and the administrative activities. When a state is planning to make a change to its state plan, the state must send state plan amendments (SPAs) to the Centers for Medicare & Medicaid Services (CMS) for review and approval. States also submit SPAs to request permissible program changes, make corrections, change reimbursement methods, or update their Medicaid or CHIP state plan with new information. Connecticut Medicaid State Plan Amendments submitted to the Centers for Medicare & Medicaid Services (CMS) within the U.S. Department of Health and Human Services (HHS) are available through the Department website.

Additional Information