Anna May Xu

Guide to the Resource Utilization Group (RUG) payment system Anna May Xu

This is your guide to Texas's Medicaid payment system for nursing homes. When newly admitted long-term care residents first arrive into a skilled nursing facility, they'll get an assessment from the staff. Each item or element on the assessment is coded into the minimum data set (MDS). A subset of the MDS directly affects the resource utilization group (RUG) calculation, which sorts the resident into one of 44 different RUG groups. Each group gets different reimbursement payments from Medicaid, so it's important to get that right.

Learn the state nursing home regulations and laws for Medicaid. This book covers exactly which MDS items affect RUG payment, the 7 major RUG group categories, and medical necessity. There's an item-by-item guide to filling out the assessment form, both for older adults and children. It also goes over what happens during an Office of the Inspector General (OIG) utilization review and how to fill in an MDS correction form.

Note: Texas uses RUG-III 34 group model, which is based on the Minimum Data Set (MDS) 3.0. They also calculate the RUG score with the index-maximizing method instead of the hierarchical method from the federal CMS.