On July 31, 2025, MassHealth issued a bulletin, Nursing Facility 194, updating the requirements for the MDS 3.0 Assessments for Nursing Facility Fee for Service Payments effective July 1, 2025. This bulletin describes how MDS assessments will be used to determine payment; the responsibilities of nursing facilities when completing and submitting assessments; and the MDS audit process. This bulletin supersedes Bulletin 190 issued in January 2025 and primarily updates the MDS Audit Structure and Expectations, as outlined below:
MDS Audit Structure and Expectations – The facility’s audit sample size will depend on the error rate from the facility’s previously completed MDS audit.
Facilities with an error rate less than 3% will have an MDS audit of the following sample size:
- Up to 40% of quarterly and annual assessments (with a focus on assessments with high PDPM scores);
- 100% of significant change assessments; and
- 100% of assessments for members with claims that billed for the behavioral indicator add-on (focused on the behavioral health sections of the MDS assessment).
Facilities with an error rate between 3% and 10% will have an MDS audit of the following sample size:
- Up to 70% of quarterly and annual assessments (with a focus on assessments with high PDPM scores);
- 100% of significant change assessments; and
- 100% of assessments for members with claims that billed for the behavioral indicator add-on (focused on the behavioral health sections of the MDS assessment).
Facilities with an error rate greater than 10% will have an MDS audit of the following sample size:
- Up to 90% of quarterly and annual assessments (with a focus on assessments with high PDPM scores);
- 100% of significant change assessments; and
- 100% of assessments for members with claims that billed for the behavioral indicator add-on (focused on the behavioral health sections of the MDS assessment).
Facilities that have undergone a CHOW (change of ownership) will be audited in the same manner as facilities with an error rate between 3% and 10% and will have an MDS audit of the following sample size:
- Up to 70% of quarterly and annual assessments (with a focus on assessments with high PDPM scores);
- 100% of significant change assessments; and
- 100% of assessments for members with claims that billed for the behavioral indicator add-on (focused on the behavioral health sections of the MDS assessment).
The bulletin also adds the following text in regard to a facility’s responsibility to adjusting a member’s MDS assessment as a result of an audit: “If the results of the audit determine that any member’s case-mix classification rating is higher than what the medical record documentation supports, the facility must adjust the corresponding Minimum Data Set (MDS) assessment(s) accordingly. The facility must correct and submit the associated MDS assessment(s) to the Centers for Medicare & Medicaid Services (CMS) within 30 days of the MDS audit date or, if a reconsideration is requested, within 30 days of the notice of the reconsideration determination.”
We encourage members to review the Updated Bulletin 194 and share with all appropriate staff at your facility.