Attachment 4e North Dakota 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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NORTH DAKOTA

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 4e: North Dakota 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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