Attachment 4c Minnesota Medicaid Pricing Schedule.pdf

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Attached to
VISN 23 36C26320R0126 0008 Updated Fargo and Central Iowa Needed Counties List, Medicaid-based Open & Continuous Solicitation, Closing Date 04 March 2023
Solicitation number
36C26320R01260003
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MINNESOTA

Medicaid Price Schedule

Classification (Medicaid RUG IV Rates) Group Medicaid Case Mix Rate (Base)

All Inclusive VA Per Diem Rate (Base + Add-on)

Rehabilitation RAE

Rehabilitation RAD

Rehabilitation RAC

Rehabilitation RAB

Rehabilitation RAA

Extensive Services Level 3 ES3

Extensive Services Level 2 ES2

Extensive Services Level 1 ES1

Special Care HIGH with Depression HE2

Special Care High with NO Depression HE1

Special Care HIGH with Depression HD2

Special Care High with NO Depression HD1

Special Care HIGH with Depression HC2

Special Care High with NO Depression HC1

Special Care HIGH with Depression HB2

Special Care High with NO Depression HB1

Special Care LOW with Depression LE2

Special Care LOW with NO Depression LE1

Special Care LOW with Depression LD2

Special Care LOW with NO Depression LD1

Special Care LOW with Depression LC2

Special Care LOW with NO Depression LC1

Special Care LOW with Depression LB2

Special Care LOW with NO Depression LB1

Clinically Complex with Depression CE2

Clinically Complex with NO Depression CE1

Clinically Complex with Depression CD2

Clinically Complex with NO Depression CD1

Clinically Complex with Depression CC2

Clinically Complex with NO Depression CC1

Clinically Complex with Depression CB2

Clinically Complex with NO Depression CB1

Clinically Complex with Depression CA2

Clinically Complex with NO Depression CA1

Behavior/Cognition with Restorative Nursing

BB2

Behavior/Cognition with NO Restorative Nursing

BB1

Attachment 4c: Minnesota Medicaid Pricing Schedule

Behavior/Cognition with Restorative Nursing

BA2

Behavior/Cognition with NO Restorative Nursing

BA1

Reduced Function with Restorative Nursing

PE2

Reduced Function with NO Restorative Nursing

PE1

Reduced Function with Restorative Nursing

PD2

Reduced Function with NO Restorative Nursing

PD1

Reduced Function with Restorative Nursing

PC2

Reduced Function with NO Restorative Nursing

PC1

Reduced Function with Restorative Nursing

PB2

Reduced Function with NO Restorative Nursing

PB1

Reduced Function with Restorative Nursing

PA2

Reduced Function with NO Restorative Nursing

PA1

NOT

Classified

AAA

Rate Weight of 1

All Inclusive VA Per Diem Rates include the following: Drugs, Supplies, Oxygen, X-Ray, Laboratory, Physicians visits, Respiratory Therapies, and Rental Equipment

END OF SECTION

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