/ en Fri, 25 Apr 2025 20:21:24 -0500 Mon, 14 Apr 25 17:13:38 -0500 <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) April 11 issued its fiscal year (FY) 2026 <a href="https://www.federalregister.gov/public-inspection/2025-06348/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities">proposed rule</a> for the skilled nursing facility (SNF) prospective payment system (PPS).</p><div class="panel module-typeC"><div class="panel-heading"><p>Key highlights</p><p>The proposed rule would:</p><ul><li>Increase aggregate SNF payments by an estimated 2.8% ($997 million) in FY 2026 relative to FY 2025.</li><li>Make technical changes to its Patient-Driven Payment Model (PDPM) ICD-10 code mapping that assigns patients to clinical categories.</li><li>For the SNF quality reporting program (QRP), remove four patient assessment data elements.</li><li>For the SNF value-based purchasing program (VBP), remove the program’s health equity adjustment.</li></ul></div></div><h2>AHA Take</h2><p>The AHA appreciates the relatively straightforward rulemaking, including the request for information on burden reduction for providers. However, the AHA continues to be concerned about the lower-than-needed market basket updates and lagging forecast error adjustments.</p><p>Highlights from the rule follow.</p><h2>PROPOSED SNF PPS PAYMENT CHANGES</h2><p>The rule’s proposed annual update would increase net payments to SNFs by an estimated 2.8% ($997 million) in FY 2026 relative to FY 2025. This includes a 3.0% market-basket update offset by a statutorily mandated productivity cut of 0.8% and a 0.6% market-basket forecast error adjustment for FY 2024.</p><p>CMS also proposes technical changes to its PDPM ICD-10 code mapping that assigns patients to clinical categories. These proposed changes can be found on <a href="https://www.cms.gov/medicare/payment/prospective-payment-systems/skilled-nursing-facility-snf/list-federal-regulations/cms-1827-p">CMS’ site</a> for this rulemaking. </p><p><strong>SNF QUALITY REPORTING PROGRAM AND VALUE-BASED PURCHASING PROGRAM </strong></p><p><u>SNF QRP.</u> Beginning with the reporting period starting Oct. 1, 2025, CMS proposes to make optional the reporting of four standardized patient assessment data elements in the Minimum Data Set focused on social determinants of health. This includes one item focused on living situation, two items focused on food insecurity and one item focused on utilities.</p><p>CMS also asks for input on future SNF QRP measure concepts and advancing digital quality measures in the SNF QRP.</p><p><u>SNF VBP Program.</u> CMS proposes to remove the program’s health equity adjustment that otherwise would be in effect beginning FY 2027. The health equity adjustment would award bonus points to SNFs based on a combination of their quality performance and the proportion of patients dually eligible for Medicare and Medicaid.</p><p><strong>REQUEST FOR INFORMATION: UNLEASHING PROSPERITY THROUGH DEREGULATION OF THE MEDICARE PROGRAM (EXECUTIVE ORDER 14192)</strong></p><p>On Jan.31, 2025, President Trump issued Executive Order (EO) 14192, "Unleashing Prosperity Through Deregulation," which states the administration’s policy to significantly reduce the private expenditures required to comply with federal regulations. CMS would like public input on approaches and opportunities to streamline regulations and reduce administrative burdens on providers, suppliers, beneficiaries and other interested parties participating in the Medicare program. The agency has made available an RFI at <a href="https://nam11.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.cms.gov%2Fmedicare-regulatory-relief-rfi&data=05%7C02%7Cjgold%40aha.org%7C4cd60274604142c4278308dd7b7460c2%7Cb9119340beb74e5e84b23cc18f7b36a6%7C0%7C0%7C638802461951091442%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=oVpGbZYA%2Bop4qTxZ4eXdtgj417%2BP2swWi8qUj%2FsAsYw%3D&reserved=0" target="_blank" title="Original URL: https://www.cms.gov/medicare-regulatory-relief-rfi. Click or tap if you trust this link.">https://www.cms.gov/medicare-regulatory-relief-rfi</a> and requests stakeholders to submit all comments in response to this RFI through the provided web link.</p><h2>NEXT STEPS</h2><p>CMS will accept comments on the SNF PPS proposed rule through June 10.</p><p>Please contact Jonathan Gold, AHA’s senior associate director of policy, at <a href="mailto:jgold@aha.org">jgold@aha.org</a>, with any questions related to payment, and Akin Demehin, AHA’s vice president of quality and safety policy, at <a href="mailto:ademehin@aha.org">ademehin@aha.org</a>, regarding any quality-related questions.</p></div><div class="col-md-4"><a href="/system/files/media/file/2025/04/cms-releases-fy-2026-skilled-nursing-facility-pps-proposed-rule-advisory-4-14-2025.pdf"><img src="/sites/default/files/2025-04/cover-cms-releases-fy-2026-skilled-nursing-facility-pps-proposed-rule-advisory-4-14-2025-r.png" data-entity-uuid data-entity-type="file" alt="Cover Image of SNF Advisory" width="640" height="828"></a></div></div></div> Mon, 14 Apr 2025 17:13:38 -0500 Skilled Nursing Facility PPS /news/headline/2025-04-11-cms-proposes-28-payment-update-snfs <p>The Centers for Medicare & Medicaid Services April 11 issued a proposed rule for the <a href="https://www.federalregister.gov/public-inspection/2025-06348/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities">skilled nursing facility</a> prospective payment system for fiscal year 2026. The proposal would increase aggregate payments by 2.8%, which reflects a 3.0% market basket update, a 0.8 percentage point cut for productivity, and an increase of 0.6 percentage points for the market basket forecast error for FY 2024. CMS also is proposing changes to some ICD-10 code mappings for payment classifications. In addition, it has included in the rule its previously published request for information seeking input on opportunities to streamline regulations and reduce burdens on providers. <br> <br>For the SNF Quality Reporting Program, CMS proposes to remove four patient assessment data elements. CMS also asks for input on future SNF QRP measure concepts and advancing digital quality measures in the SNF QRP. For the SNF value-based payment program, CMS proposes to remove the program’s health equity adjustment. <br> <br>CMS will accept public comments on the proposed rule through June 10. AHA members will receive a Regulatory Advisory with additional information. </p> Fri, 11 Apr 2025 18:23:01 -0500 Skilled Nursing Facility PPS /testimony/2025-03-11-aha-statement-house-ways-and-means-subcommittee-health-hearing-march-11-2025 <div class="container"><div class="row"><div class="col-md-8"><h2>Statement<br>of the<br>���������� Association<br>for the<br>Committee on Ways and Means<br>Subcommittee on Health<br>of the<br>U.S. House of Representatives<br>“After the Hospital: Ensuring Access to Quality Post-Acute Care”<br>March 11, 2025</h2><p>On behalf of our nearly 5,000 member hospitals and health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and our 2,425 post-acute care members, the ���������� Association (AHA) appreciates the opportunity to submit this statement for the record to the Ways and Means Subcommittee on Health on the value of post-acute care and how Congress can better support patients’ access to these critical services.</p><h2>General Policy & Regulatory Challenges</h2><p>Post-acute care is provided to patients who have been discharged from an acute-care hospital but still require services such as close medical supervision, nursing care, therapies and other support. Long-term care hospitals (LTCHs) act as a pressure relief valve for high-acuity patients needing extended hospital stays, thereby easing the burden on intensive care units (ICUs). Inpatient rehabilitation facilities (IRFs) assist patients recovering from life-changing illnesses like brain injuries, spinal cord injuries and amputations. Skilled nursing facilities (SNFs) offer rehabilitation therapy services aimed at strengthening patients and making them more independent before they return home. Home health agencies (HHs) enable seniors to remain independent by providing medical or non-medical care in their homes. Each of these facilities plays a crucial role across the continuum of care.</p><p>While each specific post-acute sector faces unique challenges, there are several policy and regulatory issues that are universal.</p><h3>Medicare Advantage</h3><p>Medicare Advantage (MA) plans are an increasingly popular choice for older Americans, and measures must be taken to ensure that patients who require post-acute care services are able to access them in a timely manner. Perhaps the biggest challenge facing post-acute care providers and their patients is the ongoing restrictions that MA plans place on access to care. The issue has been well documented by providers as well as by Department of Health and Human Services Office of Inspector General and congressional investigations.<a href="#fn1"><sup>1</sup></a><sup>,</sup><a href="#fn2"><sup>2</sup></a> The prior authorization process used by MA plans places significant administrative burden on both acute-care hospitals and post-acute care providers. Perhaps more importantly, it is directly harmful to Medicare beneficiaries — at best delaying their care and at worst outright denying medically necessary treatment.</p><p>MA plans’ practices have directly contributed to the growing discharge delay problems plaguing acute-care hospitals. While all beneficiaries have faced these delays, the increase in length of stay for MA beneficiaries seeking post-acute care has increased twice as much compared to Traditional Medicare beneficiaries. Specifically, the average length of stay (ALOS) prior to discharge to post-acute care settings has grown by 11.3% for MA patients between 2019 and 2024. However, for patients in Traditional Medicare, the ALOS has grown by only 5.2%, according to industry benchmark data from Strata Decision Technology, LLC.</p><p>Despite steps taken by the Centers for Medicare & Medicaid Services (CMS) in recent years, providers have seen little to no meaningful change in MA plan behavior and no increased access for beneficiaries. Additionally, post-acute care providers still face challenges with MA plans listing them within their networks. CMS should conduct regular audits to ensure that MA plans include robust post-acute care options with sufficient bed spaces and resources to provide the in-network care that patients need. As MA enrollment continues to grow, it is imperative that Congress continue to rein in these harmful practices to ensure that beneficiaries are not denied the care to which they are entitled.</p><h3>Ongoing Workforce Challenges</h3><p>The U.S. health care system is facing unprecedented workforce shortages, with the Bureau of Labor Statics estimating there will be 193,100 openings for nurses in each of the next 10 years.<a href="#fn3"><sup>3</sup></a> For physicians, there could be a shortage of between 37,800 and 124,000 physicians by 2034 for both primary and specialty care.<a href="#fn4"><sup>4</sup></a> Since mid-2020, post-acute care providers have seen a significant number of patient care technicians, registered nurses, and respiratory therapists, among other vital professionals, shifting employment to other organizations. Some post-acute care providers in rural areas have experienced significant challenges in filling open positions, sometimes going months without receiving an application for open registered nurses, licensed practical nurses, certified nursing assistants or key leadership roles. Staffing challenges jeopardize the ability of seniors to access the care they need and deserve.</p><p>To ensure residents and families have access to high-quality care close to home, meaningful, long-term solutions and investments in workforce development must replace stop-gap measures, reimbursement cuts and punitive regulations. The AHA encourages Congress to pass the Conrad State 30 and Physician Access Reauthorization Act (S.709/H.R.1585) and the Healthcare Workforce Resilience Act, as well as support visa recapture initiatives and continue support for the Health Resources and Services Administration’s (HRSA) health professions and nursing workforce development programs.</p><h2>Sector Specific Comments</h2><h3>Long-Term Care Hospitals</h3><p>LTCHs play a unique role for Medicare and other beneficiaries by caring for the most severely ill patients who require extended hospitalization. LTCHs offer an intensive, hospital-level of care that may not be available in other post-acute care settings. LTCH patients are typically very medically complex, with multiple organ failures, and stay in LTCHs on average for at least 25 days. Many LTCH patients depend on ventilators due to respiratory failure or similar ailments, which require highly specialized care and extended stays. In addition, LTCHs are critical partners for acute-care hospitals, alleviating capacity for overburdened ICUs and other parts of the care continuum that would otherwise be further strained without access to LTCHs for these patients.</p><p>In 2016, Congress put in place a dual-rate payment system under the LTCH prospective payment system (PPS) for Traditional Medicare beneficiaries.<a href="#fn5"><sup>5</sup></a> This fundamental change in the payment system and other coinciding market factors dramatically reshaped the landscape of both LTCHs and the beneficiaries they serve. Since implementation of the dual-rate payment system, the volume of standard LTCH cases has fallen by approximately 70% from its peak under the legacy payment system and the number of LTCH providers also has decreased by 20%. At the same time, the average acuity of LTCH patients has risen by 20% or more in that same period, and these patients are increasingly consolidated into a limited number of Diagnosis-Related Groups (DRGs).<a href="#fn6"><sup>6</sup></a> In addition, approximately one-third of all Medicare LTCH discharges nationally are paid the inpatient PPS-equivalent rate. However, these reimbursements fall well short of the cost of care. AHA’s analysis shows that as of fiscal year 2020 reimbursement for these cases totaled only 46% of the cost of care.<a href="#fn7"><sup>7</sup></a> Finally, the growth of MA has further shrunk the patient population for LTCHs as MA plans routinely inappropriately deny access to LTCHs.</p><p>The smaller, sicker patient population and dwindling reimbursement has created many challenges for LTCHs, as evidenced by the closure of so many of these facilities. The remaining patient pool is notably more acute and costly to treat, resulting in cases increasingly qualifying for high-cost outlier (HCO) payments to compensate for lack of precision in the DRGs as so many cases are consolidated into a limited number of DRGs. In 2016, the fixed-loss amount (FLA) for HCO cases, which is the amount of financial loss an LTCH must incur before qualifying for an HCO payment, was $16,423. Since that time, the FLA has risen by more than 300% to $77,048. This unsustainable figure puts LTCHs in the untenable position of having to lose tens of thousands of dollars in order to care for some of the sickest patients. Unfortunately, CMS has been unable to deviate from its current methodology to provide relief from this policy due to a congressional mandate to cap total outlier payments at 8% of total payments.<a href="#fn8"><sup>8</sup></a></p><p>The AHA appreciates this Subcommittee’s awareness of the need to provide relief to the LTCH sector and supports efforts to provide additional flexibility and funding for HCO cases, and additional flexibility to provide care for different types of patients through the standard payment system.</p><h3>Inpatient Rehabilitation Facilities</h3><p>IRF patients are typically admitted directly from an acute-care hospital following a serious accident or illness such as stroke, brain injury, amputation or others that have resulted in serious functional deficits and medical complications. IRFs provide hospital-level care, which means they are closely supervised by a physician who also oversees patients’ overall rehabilitation. The intensive course of rehabilitation provided in IRFs must include a minimum of 15 hours per week of intensive therapy services involving multiple therapy disciplines, as well as around-the-clock specialized nursing care. This level of care is critical for debilitated patients who are stable enough to be discharged from the acute-care hospital to begin intensive rehabilitation but are at risk for medical complications without continued close medical management.</p><p>The AHA continues to hear from IRFs regarding their concerns with CMS’ IRF Review Choice Demonstration (RCD). CMS initially created the IRF RCD to “assist in developing improved procedures for the identification, investigation, and prosecution of potential Medicare fraud.” However, the agency never provided credible evidence to support its belief that there may be high rates of fraud in the IRF field — it only cited its improper payment rate for IRFs, which, as it knows, is not the same as fraud. Since being operationalized by the Biden administration in 2023, CMS has not subsequently provided any evidence that the IRF RCD has revealed or assisted in uncovering any fraud. Specifically, the demonstration currently subjects 100% of IRF claims to review in both Alabama and Pennsylvania. Yet, according to CMS’ <a href="https://www.cms.gov/files/document/irf-rcd-stats-fy-2024.pdf" target="_blank" title="CMS: Review Choice Demonstration for Inpatient Rehabilitation Facility Services (IRF RCD) Quarterly Updates. Fiscal Year 2024 (Oct 2023 – Sept 2024).">most recent data</a> collected during fiscal year 2024, approximately 90% of all claims reviewed have been approved. Of those, more than 95% were approved on the initial submission. Despite this high affirmation rate and lack of evidence of any fraud, CMS says it still plans to continue its expansion of the demonstration to more than half of all states and territories, subjecting hundreds of thousands of IRF claims annually to the burdensome manual medical review process. It has become clear that this demonstration is burdensome, diverts valuable clinical resources, and is not achieving its stated objective of uncovering or preventing fraud in the Medicare program.</p><p>Therefore, the continued need for the IRF RCD remains highly dubious, and the AHA continues to encourage CMS and Congress to end this program.</p><h3>Skilled Nursing Facilities</h3><p>SNFs play another critical role for many hospitalized patients who need continued care after discharge. However, hospitals have faced increasing difficulty discharging patients to post-acute care settings, including SNFs. This challenge has largely been due to staffing shortages and the associated reduced capacity of SNFs and other providers. These shortfalls then place additional burden back on hospitals, including the need for hospitals to board patients until a discharge location can be found. Therefore, it is vital for the entire continuum of care, including for acute-care hospitals, that SNFs are properly resourced.</p><p>The AHA and its members are committed to safe staffing to ensure high-quality, patient-centered care in all health care settings, including long-term care (LTC) facilities. Yet, the process of safely staffing any health care facility is about much more than achieving an arbitrary number set by regulation. It requires clinical judgment and flexibility to account for patient needs, facility characteristics, and the expertise and experience of the care team. The Biden administration’s one-size-fits-all minimum staffing rule for LTC facilities creates more problems than it solves and could jeopardize access to all types of care across the continuum, especially in rural and underserved communities that may not have the workforce levels to support these requirements.</p><p>The AHA supports the Protecting America’s Seniors Access to Care Act (H.R. 1683) to prohibit the Department of Health and Human Services from implementing the provisions of the minimum staffing rule. We have recommended to CMS specific alternative strategies that take more patient- and workforce-centered approaches to ensuring LTC facilities have a strong foundation of policies and processes to continually assess, reassess and adjust their staffing levels. These strategies constitute starting points for further standards development, which we would encourage CMS to engage in with the assistance of patients and the entire health care continuum. Not only would these proposed alternatives support more timely and effective action by LTC facilities to address staffing challenges, but they also would be more consistent with modern clinical practice. Thus, repealing the Biden-era mandate would both protect patient access to care and allow for the development of more effective and clinically appropriate strategies to improve LTC patient outcomes.</p><h3>Home Health Agencies</h3><p>Approximately one in five hospitalized Medicare beneficiaries are discharged to HH.<a href="#fn9"><sup>9</sup></a> These services alleviate pressure on hospitals, other post-acute care sites and caregivers, who would otherwise be responsible for these patients. HH agencies also can prevent rehospitalization by safely providing needed interventions at home thus avoiding potential complications and accidents.</p><p>Over the last few years, the AHA has seen a strain on HH operations — along with other post-acute care providers — due to financial challenges, creating ripple effects throughout the continuum of care. Hospitals have seen the length of stay for patients being discharged to HH increase as they face increasing difficulty finding placements for these patients.<a href="#fn10"><sup>10</sup></a> This has been due in large part to the reductions in reimbursement to HH providers put in place by CMS since its implementation of the new Medicare fee-for-service payment system in 2020. CMS determined it must permanently cut HH payments from between 4% to 8% annually in order to meet statutory budget neutrality requirements. In addition, CMS has indicated that it intends to recoup billions more in temporary reductions in the coming years. These payment reductions, paired with staffing shortages, and other administrative burdens and costs will continue to have serious implications for access to services for Medicare beneficiaries. The AHA is thankful for the Committee’s ongoing support of home health agencies.</p><h2>Conclusion</h2><p>Thank you for your leadership on these important issues and for the opportunity to provide comments. We look forward to continuing to work with you to address these important topics on behalf of our patients and communities.</p><hr><ol><li id="fn1">HHS, Office of Inspector General (OIG); Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care (April 2022) (<a href="https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf" target="_blank">https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf</a>).</li><li id="fn2"><a href="https://www.hsgac.senate.gov/wp-content/uploads/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf" target="_blank">https://www.hsgac.senate.gov/wp-content/uploads/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf</a>.</li><li id="fn3">3<a href="https://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-6" target="_blank">https://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-6</a>.</li><li id="fn4">4<a href="https://www.aamc.org/news/press-releases/aamc-report-reinforces-mounting-physician-shortage" target="_blank">https://www.aamc.org/news/press-releases/aamc-report-reinforces-mounting-physician-shortage</a>.</li><li id="fn5">Bipartisan Budget Act Of 2013 (P.L. 113–67).</li><li id="fn6"><a href="/white-papers/2023-12-29-white-paper-medicares-ltch-outlier-policy-needs-reforms-protect-extremely-ill-beneficiaries" target="_blank">/white-papers/2023-12-29-white-paper-medicares-ltch-outlier-policy-needs-reforms-protect-extremely-ill-beneficiaries</a>.</li><li id="fn7"><a href="/system/files/media/file/2019/06/aha-cms-long-term-care-proposed-rule-fy2020-6-21-2019_0.pdf" target="_blank">/system/files/media/file/2019/06/aha-cms-long-term-care-proposed-rule-fy2020-6-21-2019_0.pdf</a>.</li><li id="fn8">Section 15009(b) of the 21ST Century Cures Act added section 1886(m)(7) to the Act.</li><li id="fn9">MedPAC; July 2024 Data Book; Section 8, Pg. 107 (<a href="https://www.medpac.gov/wp-content/uploads/2024/07/July2024_MedPAC_DataBook_Sec8_SEC.pdf" target="_blank">https://www.medpac.gov/wp-content/uploads/2024/07/July2024_MedPAC_DataBook_Sec8_SEC.pdf</a>).</li><li id="fn10"><a href="/lettercomment/2024-08-26-aha-comments-calendar-year-2025-home-health-prospective-payment-system-proposed-rule" target="_blank">/lettercomment/2024-08-26-aha-comments-calendar-year-2025-home-health-prospective-payment-system-proposed-rule</a>.</li></ol></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/03/AHA-Statement-to-House-Ways-and-Means-Subcommittee-on-Health-for-Hearing-March-11-2025.pdf" target="_blank" title="Click here to download the AHA Statement to House Ways and Means Subcommittee on Health for Hearing March 11, 2025 PDF.">Download the Testimony PDF</a></div><a href="/system/files/media/file/2025/03/AHA-Statement-to-House-Ways-and-Means-Subcommittee-on-Health-for-Hearing-March-11-2025.pdf"><img src="/sites/default/files/inline-images/Page-1-AHA-Statement-to-House-Ways-and-Means-Subcommittee-on-Health-for-Hearing-March-11-2025.png" data-entity-uuid="ef5df51a-efdf-417b-bd24-197ee16b5607" data-entity-type="file" alt="AHA Statement to House Ways and Means Subcommittee on Health for Hearing March 11, 2025 page 1." width="695" height="900"></a></div></div></div> Tue, 11 Mar 2025 12:52:15 -0500 Skilled Nursing Facility PPS <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) July 31 <a href="https://www.federalregister.gov/documents/2024/04/03/2024-06812/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities">issued</a> its fiscal year (FY) 2025 final rule for the skilled nursing facility (SNF) prospective payment system (PPS). This rule updates SNF payments and modifies CMS’ nursing home enforcement authority and the SNF Quality Reporting Program (QRP) measures and reporting requirements</p><div class="panel module-typeC"><div class="panel-heading"><h2>Key Highlights</h2><p>The rule will: </p><ul><li>Increase aggregate SNF payments by an estimated 4.2% ($1.4 billion) in FY 2025 relative to FY 2024. This includes a:<ul><li>3.0% market basket update reduced by a 0.5% productivity cut.</li><li>1.7% increase due to FY 2023 market basket forecast error.</li></ul></li><li>Make technical changes to its Patient-Driven Payment Model (PDPM) ICD-10 code mapping that assigns patients to clinical categories.</li><li>Revise CMS nursing home enforcement authority to allow the agency to impose multiple financial penalties on nursing homes with safety deficiencies.</li><li>Adopt and modify patient assessment items addressing social determinants of health (SDOH).</li></ul></div></div><h2>AHA TAKE</h2><p>While the AHA appreciates the intent of the changes CMS makes to its enforcement authority, we remain concerned that tying increased civil monetary penalties (CMPs) to the imperfect survey process will disadvantage smaller or lower-resourced facilities. We will encourage the agency both to continue to look for ways to improve the survey process and to use discretion in enforcing penalties based on instances of noncompliance with the newly finalized long-term care staffing standards.</p></div><div class="col-md-4"><a href="/system/files/media/file/2024/08/skilled-nursing-facility-prospective-payment-system-final-rule-for-fy-2025-advisory-8-27-2024.pdf"><img data-entity-uuid="978624f2-f5e1-489d-8a89-9cb5f2cff728" data-entity-type="file" src="/sites/default/files/inline-images/cover-skilled-nursing-facility-prospective-payment-system-final-rule-for-fy-2025-advisory-8-27-2024.png" width="644" height="832" alt="Skilled Nursing Facility PPS Cover Image"></a></div></div></div> Tue, 27 Aug 2024 10:50:23 -0500 Skilled Nursing Facility PPS <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) July 31 issued its fiscal year (FY) 2025 <a href="https://www.federalregister.gov/public-inspection/2024-16907/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities" target="_blank" title="Final Rule">final rule</a> for the skilled nursing facility (SNF) prospective payment system (PPS). This rule updates SNF PPS payments</p><div class="panel module-typeC"><div class="panel-heading"><h2>Key Highlights</h2><p>The rule will:</p><ul><li>Increase aggregate SNF payments by an estimated 4.2% ($1.4 billion) in FY 2025 relative to FY 2024. This includes:<ul><li>3.0% market basket update reduced by a 0.5% productivity cut.</li><li>1.7% increase due to FY 2023 market basket forecast error.</li></ul></li><li>Make technical changes to its Patient Driven Payment Model (PDPM) ICD-10 code mapping that assigns patients to clinical categories.</li><li>Revise CMS nursing home enforcement authority to allow the agency to impose multiple financial penalties on nursing homes with safety deficiencies.</li><li>Adopt and modify patient assessment items addressing social determinants of health.</li></ul></div></div><h2>AHA TAKE </h2><p>While the AHA appreciates the intent of the changes CMS makes to its enforcement authority, we remain concern that tying increased civil monetary penalties (CMPs) to the imperfect survey process will disadvantage smaller or lower-resourced facilities. We will encourage the agency both to continue to look for ways to improve the survey process and to use discretion in enforcing penalties based on instances of noncompliance with the newly finalized long-term care staffing standards.</p><p>Highlights from the rule follow. </p><h2>SNF PPS PAYMENT CHANGES</h2><p>The rule increases net payments to SNFs by an estimated 4.2% ($1.4 billion) in FY 2025 relative to FY 2024. This includes a 3.0% market-basket update, a statutorily-mandated productivity cut of 0.5% and an increase of 1.7% due to the market basket forecast error in FY 2023. The 4.2% is slightly higher than the proposed amount of 4.1% due to a slightly higher market basket update.</p><p>CMS also finalized technical changes to its PDPM ICD-10 code mapping that assigns patients to clinical categories. These changes can be found on <a href="https://www.cms.gov/medicare/payment/prospective-payment-systems/skilled-nursing-facility-snf" title="Techincal changes">CMS’ site</a> for this rule.</p><p>Additionally, CMS finalized as proposed its rebasing and revising of the SNF market basket to reflect a 2022 base year. Finally, it implemented new wage indices to incorporate updated core-based statistical areas developed by the White House Office of Management and Budget.</p><h2>NURSING HOME ENFORCEMENT</h2><p>In an effort to enhance oversight of long-term care facilities, CMS finalized changes to its regulatory authority regarding the agency’s ability to impose CMPs on facilities demonstrating deficiencies in quality or safety. Under current regulations, CMS may assess penalties on a per day (PD) or per instance (PI) basis during a survey, but not both. However, the agency finalized its proposal to enable more types of CMPs to be imposed during a survey “to be better aligned with the noncompliance identified during the survey and for more consistency of CMP amount across the nation.” The amount of CMP will increase based on the severity and/or extent of harm.</p><h2>SNF QUALITY REPORTING PROGRAM </h2><p>CMS did not adopt, modify or remove any quality measures from the Quality Reporting Program (QRP) in this rule. </p><p>CMS finalized its proposal to require SNFs to report four new patient assessment items in the SNF Minimum Data Set (MDS) under the social determinants of health category beginning with the FY 2027 SNF QRP (that is, with admissions beginning on Oct. 1, 2025). The items are currently collected in the Accountable Health Communities Health-Related Social Needs Screening Tool, and include:</p><ul><li>Living situation: addresses housing stability.</li><li>Food: addresses frequency of worry that food would run out.</li><li>Food: addresses food running out without ability to buy more.</li><li>Utilities: addresses utilities being shut off in home.</li></ul><p>In addition, CMS will modify the patient assessment item on transportation to simplify the response options and revise the look-back period. </p><p>Finally, CMS will require SNFs to participate in a data validation process beginning with the FY 2027 SNF QRP, as required by the Consolidated Appropriations Act of 2021. Specifically, the agency adopts a similar validation process for the SNF QRP that is used in the SNF Value-based Purchasing (VBP) program for assessment-based quality measures.</p><h2>SNF VALUE-BASED PURCHASING PROGRAM </h2><p>CMS finalized a number of operational updates to the VBP program that revise regulatory language to account for changes adopted for the program in previous rulemaking (such as a measure retention policy that applies to the VBP measure set that was expanded in the FY 2024 SNF PPS final rule), as well as general program policies like an extraordinary circumstances exception process and review and corrections timeline.</p><h2>FURTHER QUESTIONS</h2><p>Please contact Jonathan Gold, AHA’s senior associate director of payment policy, at <a href="mailto:jgold@aha.org" title="Jpnathan Gold Email">jgold@aha.org</a>, with any questions related to payment, and Caitlin Gillooley, AHA’s director of policy, at <a href="mailto:cgillooley@aha.org">cgillooley@aha.org</a>, regarding any quality-related questions.</p></div><div class="col-md-4"><p><a href="/system/files/media/file/2024/08/cms-releases-fy-2025-skilled-nursing-facility-pps-final-rule-bulletin-8-1-2024.pdf" target="_blank" title="Click here to download the Special Bulletin: CMS Releases FY 2025 Skilled Nursing Facility PPS Final Rule PDF."><img src="/sites/default/files/2024-08/cover-cms-releases-fy-2025-skilled-nursing-facility-pps-final-rule-bulletin-8-1-2024.png" data-entity-uuid data-entity-type="file" alt="Special Bulletin: CMS Releases FY 2025 Skilled Nursing Facility PPS Final Rule cover." width="NaN" height="NaN"></a></p></div></div></div> Thu, 01 Aug 2024 16:14:12 -0500 Skilled Nursing Facility PPS /news/headline/2024-07-31-cms-finalizes-42-payment-update-snfs-and-revises-nursing-home-enforcement-authority-fy-2025 <p>The Centers for Medicare & Medicaid Services July 31 issued a <a href="https://public-inspection.federalregister.gov/2024-16907.pdf" target="_blank">final rule</a> for fiscal year 2025 for the skilled nursing facility prospective payment system, which will increase aggregate Medicare spending by 4.2% or $1.4 billion compared to FY 2024. This reflects a 3% market basket update, a 1.7 percentage-point increase to counter the agency’s market basket error in FY 2023, and a 0.5 percentage point cut for productivity. CMS also revised its regulations regarding its nursing home enforcement authority to allow the agency to impose additional financial penalties on facilities where health and safety deficiencies are identified.</p><p>While CMS did not propose to adopt or remove any quality measures from the SNF Quality Reporting Program, the agency finalized its proposal to adopt and modify certain patient assessment items related to health-related social needs; SNFs will be required to collect and report specific data elements related to living situation, food and utilities beginning with the FY 2027 SNF QRP. CMS also finalized its proposal to adopt a data validation process for the SNF QRP beginning the same year.</p><p>CMS also finalized a number of operational updates to the SNF Value-based Purchasing program, including policies regarding measure removal and review and corrections. The agency also makes an update to the case mix methodology used to calculate the Total Nurse Staffing measure.</p><p>AHA members will receive a Special Bulletin with more details. </p> Wed, 31 Jul 2024 17:32:21 -0500 Skilled Nursing Facility PPS /news/headline/2024-05-24-aha-comments-snf-irf-proposed-rules <p>AHA commented May 24 on the Centers for Medicare & Medicaid Services' proposed rules for the <a href="/lettercomment/2024-05-24-aha-comment-letter-cms-skilled-nursing-facility-proposed-payment-rule-fy-2025">skilled nursing</a> and <a href="/lettercomment/2024-05-24-aha-comment-letter-cms-inpatient-rehabilitation-facility-proposed-payment-rule-fy-2025">inpatient rehabilitation facility</a> prospective payment systems for fiscal year 2025, expressing concerns about CMS' approach to market basket updates for both, claiming they fail to account for inflation and growth. <a href="/news/headline/2024-03-28-cms-proposes-41-payment-update-snfs-and-revise-nursing-home-enforcement-authority-fy-2025">SNFs</a> are proposed to receive a 4.1% net update for FY 2025, while <a href="/news/headline/2024-03-27-cms-proposes-28-payment-update-irfs">IRFs</a> would receive a proposed 2.8% increase. <br><br>AHA also expressed concerns about quality reporting program requirements under both proposed rules. </p> Fri, 24 May 2024 11:03:28 -0500 Skilled Nursing Facility PPS /lettercomment/2024-05-24-aha-comment-letter-cms-skilled-nursing-facility-proposed-payment-rule-fy-2025 <p>May 24, 2024</p><p>The Honorable Chiquita Brooks-LaSure<br>Administrator<br>Centers for Medicare & Medicaid Services<br>Department of Health and Human Services<br>Attention: CMS-1802-P, P.O. Box 8016<br>7500 Security Boulevard<br>Baltimore, MD 21244–1850</p><p><em><strong>Re: Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2025; 89 Fed. Reg. 23,234 (April 3, 2024).</strong></em></p><p>Dear Administrator Brooks-LaSure:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, including approximately 500 skilled-nursing facilities (SNFs), and our clinician partners — more than 270,000 affiliated physicians, two million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) fiscal year (FY) 2025 SNF prospective payment system (PPS) proposed rule.</p><p>SNFs play a critical role in the continuum of care, particularly for many hospitalized patients. For example, as AHA highlighted in <a href="/lettercomment/2023-06-05-aha-comments-fy-2024-proposed-rule-skilled-nursing-facilities" target="_blank">last year’s rulemaking</a>, hospitals have faced increasing difficulty discharging patients to post-acute care, including SNFs. This challenge has largely been due to staffing shortages and associated reduced capacity of SNFs and other providers. These shortfalls then place additional burden back on hospitals, including the need for hospitals to board patients until a discharge location can be found. Therefore, it is vital for the entire continuum of care that SNFs are properly resourced.</p><p>As such, AHA is concerned that CMS’ payment updates, in addition to increased requirements on SNFs, will exacerbate their, as well as hospitals’, financial difficulties. <strong>Therefore, we request that CMS more closely examine its process for forecasting and providing market basket updates</strong>. This is especially true for hospital-based SNFs, which care for a distinct patient population that is more resource-intensive.</p><p>View the detailed letter below. </p> Fri, 24 May 2024 10:39:09 -0500 Skilled Nursing Facility PPS <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) April 22 issued a <a href="https://public-inspection.federalregister.gov/2024-08273.pdf">final rule</a> that establishes staffing requirements for nursing homes that participate in Medicare and Medicaid. CMS estimates that about 79% of nursing homes will have to increase staffing in their facilities under the standards, which exceed existing standards in nearly all states.</p><div class="panel module-typeC"><div class="panel-heading"><h2>KEY HIGHLIGHTS</h2><ul><li>Nursing homes must provide a minimum of 3.48 hours of nursing care per resident day, including at least 0.55 hours of care from a registered nurse (RN) and 2.45 hours of care from a nurse aide (NA) per resident day.</li><li>Standards are implemented and enforced regardless of individual facilities’ patient case mix.</li><li>An RN is required to be always on-site but there is an exemption opportunity from this requirement.</li><li>Facilities are required to revise their care assessments.</li><li>CMS estimates that more than 79% of nursing facilities nationwide must increase their staffing to comply with requirements.</li></ul></div></div><h2>AHA TAKE</h2><p>The AHA strongly believes that a skilled, caring workforce is integral to delivery of high quality, safe care. Yet, the process of safely staffing any health care facility is about much more than achieving an arbitrary number set by regulation. It requires clinical judgment and flexibility to account for patient needs, facility characteristics and the expertise and experience of the care team. CMS’ one-size-fits-all minimum staffing rule for nursing homes creates more problems than it solves and could jeopardize access to all types of care across the continuum, especially in rural and underserved communities that may not have the workforce levels to support these requirements.</p><p>This final rule could lead nursing homes to reduce capacity or close outright, including those that are otherwise high performers on quality and safety metrics. The loss of these nursing home beds could adversely impact patients who have completed their hospital treatment and need continuing care in nursing facilities. The AHA <a href="/system/files/media/file/2022/12/Issue-Brief-Patients-and-Providers-Faced-with-Increasing-Delays-in-Timely-Discharges.pdf" target="_blank">has already documented</a> rising lengths of stay for hospital patients in need of skilled post-acute care, with patients waiting days, weeks or even months for post-acute care placements. As those patients continue to occupy hospital beds, other patients awaiting elective surgeries or other scheduled procedures may find their care disrupted because there is no bed for them in the hospital. Even more troubling, this final rule could lead to delays in urgent medical care as patients coming into hospital emergency departments may experience longer waits as EDs and inpatient beds are occupied by patients awaiting nursing home placements.</p><p>Lastly, this final rule could exacerbate the already serious shortages of nurses and skilled health care workers across the care continuum. Strengthening the health care workforce requires investment and innovation, not inflexible mandates. The AHA will continue to work with Congress and the Administration to advance sustainable approaches to bolstering the health care workforce and delivering high quality, safe and accessible care.</p><h2>MINIMUM STAFFING STANDARDS</h2><p>In this rule, CMS adopts federal minimum nurse staffing standards for Medicare and Medicaid long-term care (LTC) facilities largely as proposed.</p><p><strong>24-7 Onsite Registered Nurse Staffing.</strong><em> </em>CMS requires a RN to be on-site 24 hours per day and seven days per week to provide skilled nursing care to all residents in accordance with resident care plans. Currently, LTC facilities are required to have an RN onsite for eight consecutive hours a day, seven days a week. In a revision of its proposed policy, CMS allows the director of nursing (who must be, by regulation, a RN) to fulfill this requirement as long as they are available to provide direct resident care, as opposed to solely administrative duties.</p><p><strong>Minimum Hours Per Resident Day Nursing Care. </strong>CMS requires facilities to provide at minimum 3.48 hours per resident day (HPRD) of total direct nursing care to residents. HPRD is defined as the total number of hours worked by each type of staff divided by the total number of residents as calculated by CMS. Of these 3.48 hours, at least 0.55 HPRD must be provided by RNs and 2.45 HPRD must be provided by nurse aides (NA). To account for the remaining 0.48 HPRD, facilities may use any combination of nurse staff including RN, licensed practical nurse (LPN), licensed vocational nurse (LVN), or NA. CMS did not originally propose a total HPRD nursing standard; in the final rule, the agency adopts this general standard to both increase the number of hours of direct care required to be provided “while also allowing facilities to utilize other direct care nurse staff, such as LPNs/LVNs.”</p><p>The agency developed these standards using case-mix adjusted data sources, but notes that the standards are implemented and enforced independent of a facility’s case mix. That means that facilities must provide at least 0.55 RN HPRD and 2.45 NA HRPD regardless of the needs of patients in the facility.</p><p>CMS finalizes with some modification proposals to revise existing facility assessment requirements. CMS will move the regulatory language to a standalone section in the Code of Federal Regulations and update requirements of what the assessment must address or include to ensure that facilities have an efficient process for consistently assessing and documenting the necessary resources and staff that the facility requires. For example, CMS requires LTC facilities to incorporate the input of facility staff, leadership and management into their assessment and develop and maintain a plan to maximize recruitment and retention of direct care staff.</p><p>In the final rule, CMS notes that swing-beds are not subject to the nursing services regulations subject to changes in this rule; instead, they are subject to hospital conditions of participation.</p><p><strong>IMPLEMENTATION POLICIES</strong></p><p><strong>Compliance Timeline.</strong><em> </em>CMS finalizes, with some modification, its proposal to stagger the implementation dates of these requirements to allow facilities time to prepare. Specifically, the agency will expect compliance with finalized provisions by the following timeline.</p><ul><li>Non-rural facilities must demonstrate compliance within:<ul><li>Facility assessment updates 90 days after publication of the final rule.</li><li>3.48 HPRD total nurse staffing and 24/7 RN requirements two years after publication of the final rule.</li><li>Minimum 0.55 RN and 2.45 NA HPRD requirements three years after publication.</li></ul></li><li>Rural facilities must demonstrate compliance within:<ul><li>Facility assessment updates 90 days after publication of the final rule.</li><li>3.48 HPRD total nurse staffing and 24/7 RN requirements three years after publication of the final rule.</li><li>Minimum 0.55 RN and 2.45 NA HPRD requirements five years after publication.</li></ul></li></ul><p><strong>Exemptions. </strong>CMS will allow hardship exemptions to the minimum HPRD standards in limited circumstances when nursing facilities meet all the following requirements.</p><ul><li>The facility is in an area where the supply of applicable health care staff is not sufficient to meet area needs, defined as being at least 20% below the national average in provider-to-population ratio for nursing workforce.</li><li>The facility discloses its exemption status by posting a notice of the exemption in a prominent location in the facility and provides each resident and prospective resident a detailed notice of the exemption status.</li><li>The facility demonstrates good-faith efforts to hire and provides documentation of its financial commitment to staffing.</li></ul><p>The facility will be ineligible to receive an exemption if it has failed to submit payroll-based journal data in accordance with federal regulations, is a Special Focus Facility, has been cited for widespread or a pattern of insufficient staffing with resultant resident actual harm, or has been cited at the “immediate jeopardy” level of severity with respect to insufficient staffing within the 12 months preceding the survey during which the facility’s non-compliance is identified.</p><p>CMS also allows for hardship exemptions from the 24/7 onsite RN requirement — a provision not included in the proposed rule. A facility may qualify for a hardship exemption that excuses eight hours a day from the 24-hour requirement if the facility is in an area where the RN-to-population ratio is a minimum of 20% below the national average (as calculated by CMS using data from the Bureau of Labor Statistics and Census Bureau). If a facility receives this exemption, they must have an RN, nurse practitioner, physician assistant or physician available to respond immediately to telephone calls from the facility.</p><p>Determinations regarding exemptions will be made during a survey. CMS may impose enforcement actions (or “remedies”) against LTC facilities deemed non-compliant including termination of the provider agreement, denial of payment for all Medicare and/or Medicaid individuals by CMS, and/or civil monetary penalties. The agency notes that it will publish more details on how compliance will be assessed and how enforcement remedies will be imposed after the publication of the final rule in advance of each implementation date for the different provisions of the rule.</p><p><strong>STATE MEDICAID AGENCIES</strong></p><p>CMS also finalizes its proposed new regulations regarding State Medicaid agencies and requires these agencies to report on the percent of payments for Medicaid-covered services in nursing facilities and intermediate care facilities for individuals with intellectual disabilities that are spent on compensation for direct care workers and support staff. The agency believes this will inform efforts to address the link between payment to institutional direct care and support staff and access to/quality of services for Medicaid beneficiaries.</p><p><strong>FURTHER QUESTIONS</strong></p><p>Please contact Caitlin Gillooley, AHA’s director of behavioral health and quality policy, at <a href="mailto:cgillooley@aha.org">cgillooley@aha.org</a> or (202) 626-2267 with any questions.</p></div><div class="col-md-4"><a href="/system/files/media/file/2024/04/cms-establishes-minimum-staffing-standards-for-nursing-homes-bulletin-4-24-24.pdf" target="_blank"><img src="/sites/default/files/2024-04/cover-cms-establishes-minimum-staffing-standards-for-nursing-homes-bulletin-4-24-24.png" data-entity-uuid data-entity-type="file" alt=" Cover Special Bulletin: CMS Establishes Minimum Staffing Standards for Nursing Homes" width="NaN" height="NaN"></a></div></div></div> Wed, 24 Apr 2024 15:19:53 -0500 Skilled Nursing Facility PPS <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) March 28 <a href="https://public-inspection.federalregister.gov/2024-06812.pdf" title="Proposed Rule for Skilled Nursing Facilities" target="_blank">issued</a> its fiscal year (FY) 2025 proposed rule for the skilled nursing facility (SNF) prospective payment system (PPS).</p><div class="panel module-typeC"><div class="panel-heading"><h2>KEY HIGHLIGHTS</h2><p>CMS’ proposed policies would: </p><ul><li>Increase aggregate SNF payments by an estimated 4.1% ($1.3 billion) in FY 2025 relative to FY 2024. This includes:<ul><li>A 2.8% market basket update reduced by a 0.4% productivity cut.</li><li>A 1.7% increase due to a FY 2023 market basket forecast error.</li></ul></li><li>Rebase the SNF market basket using 2022 cost data.</li><li>Revise CMS nursing home enforcement authority to allow the agency to impose multiple financial penalties on nursing homes with safety deficiencies.</li><li>Adopt and modify patient assessment items addressing social determinants of health.</li></ul></div></div><h2>AHA TAKE</h2><p>This proposed rule does not make any major or unexpected payment changes to the SNF PPS. However, CMS does propose to rebase the SNF market basket. AHA is concerned that it would decrease the relative weights of wages and benefits for SNF employees, which may not allow for it to properly account for increasing labor costs.</p><h2>WHAT YOU CAN DO</h2><ul><li>Share this advisory with your senior management team to examine the impact these payment changes would have on your organization in FY 2025.</li><li>Attend an upcoming AHA webinar to be announced in the coming days on the proposed rule.</li><li>Submit to CMS by May 28 a comment letter explaining the rule’s impact on your patients, staff, facility and local health care partners.</li></ul><p>View the detailed Regulatory Advisory below.</p></div><div class="col-md-4"><a href="/system/files/media/file/2024/04/skilled-nursing-facility-pps-proposed-rule-for-fy-2025-bulletin-4-24-24.pdf" target="_blank"><img src="/sites/default/files/2024-04/cover-skilled-nursing-facility-pps-proposed-rule-for-fy-2025-bulletin-4-24-24.png" data-entity-uuid data-entity-type="file" alt=" Cover Skilled Nursing Facility PPS Proposed Rule for FY 2025" width="NaN" height="NaN"></a></div></div></div> Wed, 24 Apr 2024 10:46:50 -0500 Skilled Nursing Facility PPS