Fiscal Year (FY) 2022 Skilled Nursing Facility Prospective Payment System Proposed Rule (CMS 1746-P) Fact Sheet

CMS issued a proposed rule that would update Medicare payment policies and rates for skilled nursing facilities under the Skilled Nursing Facility (SNF) prospective payment system (PPS) for fiscal year (FY) 2022. In addition, the proposed rule includes proposals for the SNF Quality Reporting Program (QRP), and the SNF Value-Based Program (VBP) for FY 2022. CMS is publishing this proposed rule consistent with the legal requirements to update Medicare payment policies for SNFs on an annual basis. The major provisions of the proposed rule include the following:

• FY 2022 Proposed Updates to the SNF Payment Rates  
• Methodology for Recalibrating the PDPM Parity Adjustment
• Rebase and Revise the SNF Market Basket
• Section 134 of the Consolidated Appropriations Act, 2021  – New Blood Clotting Factor Exclusion from SNF Consolidated Billing 
• Proposed changes in PDPM ICD-10 Code Mappings 
• Skilled Nursing Facility Quality Reporting Program (SNF QRP) update
• Closing the Health Equity Gap – RFI
• Skilled Nursing Facility (SNF) Healthcare-Associated Infections (HAI) Requiring Hospitalization Measure
• COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure
• Transfer of Health (TOH) Information to the Patient-PAC Quality Measure
• Public Reporting of Quality Measures with Fewer than Standard Numbers of Quarters Due to COVID-19 Public Health Emergency (PHE) Exemptions
• Fast Healthcare Interoperability Resources (FHIR) in support of Digital Quality Measurement in Quality Reporting Programs – RFI
• Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program
• Proposal to suppress the SNF readmission measure in the SNF VBP Program
• Expanded SNF VBP Program

SNF Quality Reporting Program (QRP) quality data on Care Compare are updated on a quarterly basis.

The Centers for Medicare & Medicaid Services (CMS) will be transitioning to a new data source for providers’ demographic data for all five Post-Acute Care (PAC) provider types (Skilled Nursing Facilities / Nursing Facilities (SNF/NFs), Home Health Agencies (HHAs), Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs) and Hospices).  These demographic data include such items as the provider name, provider-mailing address, provider physical address, State, ZIP Code, etc.  These provider demographic data are displayed on the Provider and Quality Measure reports generated from the Quality Improvement and Evaluation System (QIES) Certification and Survey Provider Enhanced Reports (CASPER) Reporting application for SNF/NF and Hospice providers and reports generated from Internet Quality Improvement and Evaluation System (iQIES) for HHA, IRF, and LTCH providers. Additionally these same demographic data are displayed on the public reporting websites such as the Provider Data Catalog (PDC).

Historically provider demographic data have been maintained in the Automated Survey Processing Environment or ASPEN software; however, CMS will be transitioning to use the demographic information from Provider Enrollment, Chain and Ownership System (PECOS).  While this transition is underway, a final date when all demographic data will be obtained from PECOS has not been identified.  During this transition, all SNF/NF providers will be responsible to ensure their latest demographic data are updated and available in both the ASPEN and PECOS systems. 

A referencing document that outlines the steps each PAC provider should follow can be accessed in the Downloads section of this webpage. Should you have questions regarding this updated process, please contact the iQIES help desk by email at iQIES@cms.hhs.gov or by phone at (800) 339-9313.

REGISTRATION OPEN – SNF QRP: Achieving a Full APU

The Centers for Medicare & Medicaid Services (CMS) will host a webinar on Tuesday, March 30, 2021, from 1:00 p.m. to 2:30 p.m. ET to educate providers about the Annual Payment Update (APU) process to achieve full APU. This webinar will cover the relationship between the APU and the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP), associated data submission requirements, and the reconsideration process for providers who are identified as being noncompliant.

Please register only if you know you will be able to attend the webinar, as space is limited. If you would like your name placed on a list to receive an email notification when the recorded version of the webinar is available, please CLICK HERE to be placed on an email notification list.

CLICK HERE to register for the SNF QRP: Achieving a Full APU Webinar.

If you have questions or need additional information regarding the logistics of this training session, please email the PAC Training mailbox at PACTraining@econometricainc.com.

Updates

March 1, 2021

SNF QRP FAQs

An update to the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Frequently Asked Questions (FAQs) document is now available. This document has been updated to reflect the finalized policies for the SNF QRP in Fiscal Year (FY) 2021 and other useful resources available to providers.

Contents

Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Overview

1. What is a Quality Reporting Program?

2. What are the current measures in the SNF QRP?

3. What are the FY 2021 updates to the SNF QRP?

Staying Informed About the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)

4. What is the process for adding and removing measures from the SNF QRP?

5. Are there other resources on the SNF QRP website I can use to stay up-to-date?

6. Where can I find SNF QRP training materials?

Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Technical Requirements

7. How are data collected and submitted for the SNF QRP?

8. Which items on the SNF MDS are considered for compliance determination?

9. What are the requirements for the SNF to be considered compliant?

10. What are the data submission deadlines for the SNF QRP?

11. Does the definition of “quarter” for the quarterly MDS data submission deadlines include patients admitted during that quarter, discharged during that quarter, or both?

12. What is QIES? How can I request access to QIES?

The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) and the Minimum Data Set (MDS)

13. What is the current version of the MDS?

14. Where can I find the MDS 3.0 Resident Assessment Instrument (RAI) Manual for the SNF QRP?

15. Who can complete a SNF MDS?

Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Reconsiderations, Exceptions, and Extensions

16. Does the Centers for Medicare & Medicaid Services (CMS) tell SNFs if they are noncompliant with the QRP requirements?

17. I received a letter of notification that my SNF is non-compliant with the SNF QRP requirements. Can I ask CMS to reconsider the decision?

18. The county where our SNF is located was affected by a natural disaster. Are we excepted from the QRP reporting requirements?

Other Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Frequently Asked Questions

19. Does my SNF need to report health care–acquired infection data under the SNF QRP?

20. My facility’s demographic data are incorrect on Care Compare. How do I correct them?

21. Where are SNF quality measure data publicly reported?

22. Which SNF quality measures are reported on the Care Compare website?

23. Who can I contact with a specific question about the SNF QRP?

Sections addressing SNF VBP changes and access to services for hemophilia residents:

SEC. 111. IMPROVING MEASUREMENTS UNDER THE SKILLED NURSING FACILITY VALUE-BASED PURCHASING PROGRAM UNDER THE MEDICARE PROGRAM.

    (a) In General.--Section 1888(h) of the Social Security Act (42

U.S.C. 1395yy(h)) is amended--

        (1) in paragraph (1), by adding at the end the following new

    subparagraph:

            ``(C) Exclusions.--With respect to payments for services

        furnished on or after October 1, 2022, this subsection shall

        not apply to a facility for which there are not a minimum

        number (as determined by the Secretary) of--

                ``(i) cases for the measures that apply to the facility

            for the performance period for the applicable fiscal year;

            or

                ``(ii) measures that apply to the facility for the

            performance period for the applicable fiscal year.'';

        (2) in paragraph (2)(A)--

            (A) by striking ``The Secretary shall apply'' and inserting

        ``The Secretary--

                ``(i) shall apply'';

            (B) by striking the period at the end and inserting ``;

        and''; and

            (C) by adding at the end the following:

                ``(ii) may, with respect to payments for services

            furnished on or after October 1, 2023, apply additional

            measures determined appropriate by the Secretary, which may

            include measures of functional status, patient safety, care

            coordination, or patient experience.

        Subject to the succeeding sentence, in the case that the

        Secretary applies additional measures under clause (ii), the

        Secretary shall consider and apply, as appropriate, quality

        measures specified under section 1899B(c)(1). In no case may

        the Secretary apply more than 10 measures under this

        subparagraph.'';

        (3) in subparagraph (A) of each of paragraphs (3) and (4), by

    striking ``measure'' and inserting ``measures''; and

        (4) by adding at the end the following new paragraph:

        ``(12) Validation.--

            ``(A) In general.--The Secretary shall apply to the

        measures applied under this subsection and the data submitted

        under subsection (e)(6) a process to validate such measures and

        data, as appropriate, which may be similar to the process

        specified in section 1886(b)(3)(B)(viii)(XI) for validating

        inpatient hospital measures.

            ``(B) Funding.--For purposes of carrying out this

        paragraph, the Secretary shall provide for the transfer, from

        the Federal Hospital Insurance Trust Fund established under

        section 1817, of $5,000,000 to the Centers for Medicare &

        Medicaid Services Program Management Account for each of fiscal

        years 2023 through 2025, to remain available until expended.''.

    (b) Report by MedPAC.--Not later than March 15, 2022, the Medicare

Payment Advisory Commission shall submit to Congress a report on

establishing a prototype value-based payment program under a unified

prospective payment system for post-acute care services under the

Medicare program under title XVIII of the Social Security Act (42

U.S.C. 1395 et seq.). Such report--

        (1) shall--

            (A) consider design elements such as--

                (i) measures that are important to the Medicare program

            and to beneficiaries under such program;

                (ii) methodologies for scoring provider performance and

            effects on payment; and

                (iii) other elements determined appropriate by the

            Commission; and

            (B) analyze the effects of implementing such prototype

        program; and

        (2) may--

            (A) discuss the possible effects, with respect to the

        Medicare program, on program spending, post-acute care

        providers, patient outcomes, and other effects determined

        appropriate by the Commission; and

            (B) include recommendations with respect to such prototype

        program, as determined appropriate by the Commission, to

        Congress and the Secretary of Health and Human Services.

 SEC. 134. IMPROVING ACCESS TO SKILLED NURSING FACILITY SERVICES FOR HEMOPHILIA PATIENTS.

(a) In General.--Section 1888(e)(2)(A)(iii) of the Social Security

Act (42 U.S.C. 1395yy(e)(2)(A)(iii)) is amended by adding at the end

the following:

                    ``(VI) Blood clotting factors indicated for the

                treatment of patients with hemophilia and other

                bleeding disorders (identified as of July 1, 2020, by

                HCPCS codes J7170, J7175, J7177-J7183, J7185-J7190,

                J7192-J7195, J7198-J7203, J7205, J7207-J7211, and as

                subsequently modified by the Secretary) and items and

                services related to the furnishing of such factors

                under section 1842(o)(5)(C), and any additional blood

                clotting factors identified by the Secretary and items

                and services related to the furnishing of such factors

                under such section.''.

    (b) Effective Date.--The amendment made by subsection (a) shall

apply to items and services furnished on or after October 1, 2021.

The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training course that provides an overview of the assessment and coding of the Drug Regimen Review standardized patient assessment data elements (SPADEs) found in the Medications Section of the guidance manuals.

This 45-minute course is intended for providers in Home Health Agencies (HHAs), Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs), and Skilled Nursing Facilities (SNFs), and is designed to be used on demand anywhere you can access a browser.

From Data Elements to Quality Measures – Cross-Setting QRP Web-Based Training

The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training course that provides a high-level overview of how data elements within CMS patient/resident assessment instruments are used to construct quality measures (QMs) across post-acute care (PAC) settings. The PAC settings included are those covered under the Centers for Medicare & Medicaid Services (CMS) Quality Reporting Programs (QRPs) for Home Health Agencies (HHAs), Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs) and Skilled Nursing Facilities (SNFs). Information covered will include a short review of the QRPs’ cross-setting quality measures (QM), how data elements feed into these cross-setting QMs, how QMs are calculated and appear on QM reports and how to access and use this data for quality improvement. 

CMS has issued its 2020 measures under consideration (MUC) list. It includes two proposed SNF QRP QMs. The list includes more detailed info about proposed numerators, denominators, and rationales for each measure:

 MUC20- 0002: Skilled Nursing Facility Healthcare Associated Infections Requiring Hospitalization (outcome measure)

This measure will estimate the risk-adjusted rate of healthcare-associated infections (HAIs) that are acquired during skilled nursing facility (SNF) care and result in hospitalizations. The measure is risk adjusted to “level the playing field” and to allow comparison of measure performance based on residents with similar characteristics between SNFs. It is important to recognize that HAIs in SNFs are not considered “never-events.” The goal of this risk-adjusted measure is to identify SNFs that have notably higher rates of HAIs that are acquired during SNF care and result in hospitalization, when compared to their peers

More information:

Draft Measure Specifications: Skilled Nursing Facility Healthcare-Associated Infections Requiring Hospitalizations For The Skilled Nursing Facility Quality Reporting Program

MUC20- 0044: SARS-CoV-2 Vaccination Coverage among Healthcare Personnel (process measure)

This measure tracks SARS-CoV-2 vaccination coverage among healthcare personnel (HCP) in IPPS hospitals, inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), inpatient psychiatric facilities, ESRD facilities, ambulatory surgical centers, hospital outpatient departments, skilled nursing facilities, and PPS-exempt cancer hospitals.

CMS press release:

New Measures Under Consideration Mark a Milestone for CMS’s Reimagined Quality Strategy to Increase Digital Innovation and Reduce Burden

Measures advance better quality care

The Centers for Medicare & Medicaid Services (CMS) today unveiled its 2020 list of quality and efficiency measures under consideration. Quality measures are tools the agency uses to collect data from providers on the effectiveness, safety, efficiency, and timeliness of care beneficiaries receive. Every year, CMS evaluates all measures in its programs, proposing to remove those that have become less relevant and proposing new measures that may be more meaningful based on review by external health care experts. This year, almost all of the measures proposed would be collected digitally, meaning information comes from claims and other electronic sources, and would not require doctors to retrieve data manually. As a signal for CMS’s broader direction as the agency puts patients over paperwork in the push for quality and innovation, the 2020 list of measures under consideration represents “a first” on several important fronts, particularly where digital innovation and reducing administrative burden are concerned.

Releasing the list is the first step in the “pre-rulemaking process,” when measures under consideration go to the National Quality Forum’s Measure Applications Partnership (MAP). Funded by CMS, the MAP is an independent, voluntary collaborative of organizations representing a broad group of stakeholders interested in or affected by the use of quality and efficiency measures and convened per statute to provide input on their selection. In a broader “CMS first,” a majority of measures under consideration in 2020 also rely on digital reporting of existing information, which can help providers spend more time with patients and less time collecting data. Coupled with a limited number of non-digital measures emphasizing patient-reported health outcomes, another priority for CMS, this digital innovation continues the reimagined quality strategy announced by CMS Administrator Seema Verma in 2017 as part of the Meaningful Measures initiative.

“We launched Meaningful Measures because too many providers were wasting precious time and resources reporting on quality metrics, many of which were barely relevant to their specialty,” said CMS Administrator Verma. “Over the last four years, this initiative has delivered better, less onerous metrics that are actually useful to those who use them. The measures we are announcing today represent more of the same. They prioritize health outcomes, reduce burden, and give providers more time to do the work they entered medicine to do: treat patients.”

Quality measures form the backbone of CMS’s ongoing effort to promote health for millions of Americans. The previously adopted measure for controlling high blood pressure, for example, helps CMS evaluate the quality of care by collecting data on the percentage of beneficiaries 18-85 years old whose high blood pressure has been adequately controlled during the measurement period, meaning their blood pressure readings were less than 140/90 mmHg. Additionally, reporting on these measures holds clinicians accountable for ensuring the best possible outcomes for beneficiaries.

However, many quality measures have required intensive manual data collection and individual chart reviews, robbing doctors and other health professionals of valuable time spent caring for Americans. Over the last several years, CMS has been working to reduce provider burden by shifting toward measures that can be collected digitally using existing data. That strategy has the next iteration of the Meaningful Measures framework – or Meaningful Measures 2.0, the comprehensive initiative launched in 2017 to identify high-priority areas for quality measurement and improvement – at its heart.

Though including a measure on the consideration list does not guarantee its adoption, the list represents a key first step and one built on collaboration between CMS and providers. Annually, the agency invites health care specialty societies and other stakeholder groups to submit candidate measures, due this year by June 30, narrowed down to identify promising candidates that warrant expert review as “measures under consideration.” The 2020 list – which includes a number of new measures, as well as several updates to modernize or replace existing measures – features:

·  Five outcome measures (measures that focus on the results of health care provided through Medicare), such as the rate of health care-associated infections requiring hospitalization for residents of skilled nursing facilities;

·  Five process measures (measures that emphasize efforts to promote standardized best practices), such as conducting kidney health evaluations or implementing interventions for patients with pre-diabetes (the medical term for blood glucose levels that are high but not yet high enough for a type-2 diabetes diagnosis). Importantly, the 2020 list includes three process measures for the coronavirus disease 2019 (COVID-19) vaccine. The measures under consideration list proposes looking at:

·  Vaccination coverage among health care personnel,

·  Vaccination by clinicians, and

·  Vaccination coverage for patients in End-Stage Renal Disease (ESRD) facilities;

·  Five cost/resource use measures (measures that evaluate how frequently health care items or services may be used, as well as how much they might cost) – including, for example, episode-based costs associated with addressing diabetes or asthma/chronic obstructive pulmonary disease;

·  Three composite measures (which summarize overall quality of care across multiple measures through the use of one value or piece of information); and

·  Two patient reported outcomes measures (measures where the information comes directly from the patient).

All but three measures under consideration rely on digital rather than traditional “pen-and-paper” data collection. Of the non-digital measures, two are measures aimed at assessing COVID-19 vaccinations among health care personnel and patients in ESRD facilities, and the other reflects key patient-reported health outcomes, which help prioritize patient voices and empower patients to take an active role in their health.

CMS expects to receive the MAP’s input on the 2020 measures under consideration by February 1, 2021. Experts at CMS and the Department of Health and Human Services will work collaboratively based on this assessment to select final measures available for further public comment through a notice of proposed rulemaking in the Federal Register.

On 12/7/20, the federal government, through the Health Resources and Services Administration (HRSA) operating under the U.S. Department of Health and Human Services (HHS), announced it will distribute $523 million in second round performance payments to over 9,000 nursing homes. These nursing homes are being rewarded for successfully reducing COVID-19 related infections and deaths between September and October.

In August, HHS announced plans to distribute $5 billion in additional Provider Relief Fund (PRF) payments to nursing homes from which $2 billion would be dedicated to establishing an incentive-based program that rewards nursing homes that create and maintain safe environments for their residents. In October, HHS announced the first round of awardees receiving $331 million in payments for keeping new COVID-19 infection and mortality rates among residents lower than the communities they serve – as analyzed against CDC data between August and September. This announcement is the second of five evaluation cycles rewarding nursing homes for their performance reducing nursing home infection and mortality rates. Nursing homes will begin receiving payments December 9.

Nursing Home Infection and Mortality Outcomes

HHS found that between September and October, of the 13,251 eligible nursing homes, 9,248, or 69 percent, met the incentive program's infection control criteria. While less than the first cycle, the collective efforts of these nursing homes resulted in over 3,900 fewer infections relative to the rates seen in the communities where they exist. Against the mortality criteria, 9,128, or 68 percent of eligible nursing homes, achieved outcomes that met or exceeded the expected COVID-19 mortality rate for their facility.

This announcement rewards nursing homes for a period in time. HHS recognizes COVID-19 is a fluid challenge and it continues to take a devastating toll on nursing homes stretched thin and disproportionately impacted due in part to factors such as their congregate setting and the existing vulnerabilities of older residents with comorbidities. This new round of incentive payments will bolster the $15 billion already distributed to nursing homes in both Targeted and General Distribution PRF funding. Recipients may use this funding to acquire additional personal protective equipment or other efforts to help slow the spread of COVID-19.

Continued Support for Nursing Homes

Two COVID-19 vaccine candidates have been submitted to the FDA for Emergency Use Authorization approval. In recognition of this administration's focus on protecting older Americans and as driven by data, the CDC, accepted the recommendation of the Advisory Committee on Immunization Practices (ACIP), that states prioritize nursing home residents for tier one COVID-19 vaccine distribution, once available. Placing nursing home residents and health care personnel at the top of the list for the COVID-19 vaccine will be a game-changer in what has been a difficult fight against the pandemic. Paired with continued funding directly tied to COVID-19 infection and mortality rate reductions, HHS is exhausting all measures to ensure nursing homes nationwide are safe. Residents and their families can be assured help is on the way.

Finally, HHS is reminding all certified nursing homes that free interactive training and mentoring is available through the Agency for Healthcare Research and Quality to advance COVID-19 preparedness, safety, and infection control. To date, only half of all U.S. nursing homes have enrolled but registration remains open. The Centers for Medicare and Medicaid Services also has a free training program for nursing homes. These are vital resources nursing homes should employ to combat this pandemic.

The October 2020 refresh of SNF QRP data is now available on Nursing Home Compare (NHC), as well as the Nursing homes including rehab services web pages within Care Compare (CCXP) and Provider Data Catalog (PDC).

The data are based on quality assessment data submitted by SNFs to CMS from Quarter 1 2019 through Quarter 4 2019 (01/01/2019 –12/31/2019); and the annual update of the claims-based measures data from Quarter 4 2017 – Quarter 3 2019 (10/01/2017 – 9/30/2019).