CMS Proposed Rules Will Impact SNFs and Hospice Providers

Original story posted on: May 6, 2019

Proposed rules also include new payment models.

The Centers for Medicare & Medicaid Services (CMS) has been quite busy these last few weeks issuing the proposed payment rules for 2020 and making some other announcements.  Here is an update on other regulatory activities of interest.

On April 22, 2019, the CMS Innovation Center announced the Primary Cares Initiative (PCI), which will present eligible providers and other entities with the opportunity to engage in value-based payment and direct contracting payment models for primary care beginning in January 2020.  There are two tracks; the PCF track, which is intended for individual primary care practices and seeks to reward providers for reductions in hospital utilization and total cost of care through performance-based payment adjustments. Also, practices that specialize in serving high-need and/or seriously ill populations will receive adjusted payments to account for the populations served. Providers that participate in these models will qualify as participating in an Advanced Alternative Payment Model and be eligible to receive full bonus payments under CMS’s Medicare Incentive Payment System (MIPS).  The DC track is intended for a broader set of stakeholders with experience accepting a financial risk and serving larger patient populations. Medicare Advantage plans can also apply for DC, although details are forthcoming. Entities interested in pursuing DC can choose from one of three models; DC Professional, DC Global; DC Geographic (see table below). The form of the capitated payment they receive will depend on the model they select. The capitated arrangements range from reimbursing for a portion of the expected primary care costs to the total cost of care.

On April 19 CMS published a proposed rule on FY2020 hospice payments. This rule “re-bases” per diem payments for hospice to better align them with the actual cost of care. CMS is also proposing to modify the existing hospice election statement content requirements to increase coverage transparency for patients who choose to elect hospice. Hospices would be required to provide, upon request, an election statement addendum with a list and rationale for items, drugs, and services that the hospice has determined to be unrelated to the terminal illness and related conditions to the beneficiary (or representative), other providers that are treating such conditions, and to Medicare contractors. Having this information and education will empower patients to make an informed decision when deciding to elect hospice.

Also, on April 19, CMS issued a proposed rule [CMS-1718-P] for Fiscal Year (FY) 2020 that updates the Medicare payment rates and the quality programs for skilled nursing facilities (SNFs). CMS is continuing its efforts to move from volume to value-based purchasing in all provider types. The CMS Patient Driven Payment Model (PDPM), will be effective Oct. 1, 2019, under the SNF Prospective Payment System (PPS) for classifying patients in a covered Medicare Part A SNF stay. PDPM utilizes ICD-10 codes to classify SNF patients into certain payment groups.  This, of course, makes complete and accurate ICD-10 coding for SNF patients even more critical. As part of the SNF Quality Reporting Program, CMS proposes to adopt two new quality measures in FY 2020 to assess how health information is shared. The two proposed measures are: 1) Transfer of Health Information from the SNF to another Provider, and 2) Transfer of Health Information from the SNF to the Patient.

On April 18, CMS issued a proposed rule that would update Medicare payment policies and rates for the Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) and the IPF Quality Reporting (IPFQR) Program for FY 2020. CMS estimates total IPF payments to increase by 1.7 percent or $75 million in FY 2020.  For FY 2020, CMS is proposing to rebase and revise the IPF market basket to reflect a 2016 base year from a 2012 base year.  And, for FY 2020, CMS is proposing to adopt one new claims-based measure beginning with the FY 2021 payment determination and subsequent years. This measure, Medication Continuation Following Inpatient Psychiatric Discharge (National Quality Forum #3205), assesses whether patients admitted to IPFs with diagnoses of Major Depressive Disorder (MDD), schizophrenia, or bipolar disorder filled at least one evidence-based medication within two days prior to discharge or during the 30-day post-discharge period.

Comment periods on these proposed rules are 60 days from date of publication, so comments are due in the latter part of June. 

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Stanley Nachimson, MS

Stanley Nachimson, MS is principal of Nachimson Advisors, a health IT consulting firm dedicated to finding innovative uses for health information technology and encouraging its adoption.   The firm serves a number of clients, including WEDI, EHNAC, the Cooperative Exchange, the Association of American Medical Colleges, and No World Borders.  Stanley is focusing on assisting health care providers and plans with their ICD-10 implementation and is the director of the NCHICA-WEDI Timeline Initiative.  He serves on the Board of Advisors for QualEDIx Corporation.

Stanley served for over 30 years in the US Department of Health and Human Services in a variety of statistical, management, and health technology positions.  His last ten years prior to his 2007 retirement were spent in developing HIPAA policy, regulations, and implementation planning and monitoring, beginning CMS’s work on Personal Health Records and serving as the CMS liaison with several industry organizations, including WEDI and HITSP.  He brings a wealth of experience and information regarding the use of standards and technology in the health care industry.

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