CMS is delaying the release of the updated versions of the Minimum Data Set (MDS) needed to support the Transfer of Health (TOH) Information Quality Measures and new or revised Standardized Patient Assessment Data Elements (SPADEs) in order to provide maximum flexibilities for providers of Skilled Nursing Facilities (SNFs) to respond to the COVID-19 Pubic Health Emergency (PHE).

The release of updated versions of the MDS will be delayed until October 1st of the year that is at least 2 full fiscal years after the end of the COVID-19 PHE. For example, if the COVID-19 PHE ends on September, 20, 2020, SNFs will be required to begin collecting data using the updated versions of the item sets beginning with patients discharged on October 1, 2022.

Following the PHE, CMS will announce training opportunities for providers via this webpage and announcements sent out via email distribution lists and posted on the Medicare Learning Network.

Note that the COVID-19 reporting and SNF QRP reporting changes both will go into effect on May 8 since the effective date is the publication date.

Medicare and Medicaid Programs, Basic Health Program, and Exchanges: Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program

ACTION: Interim final rule with comment period.

Requirement for Facilities to Report Nursing Home Residents and Staff Infections, Potential Infections, and Deaths Related to COVID-19

We are revising § 483.80 to establish explicit reporting requirements for long-term care (LTC) facilities to report information related to COVID-19 cases among facility residents and staff. These reporting requirements are applicable on the effective date of this IFC.

SNF QRP

We are revising the compliance date for the SNF QRP to October 1st of the year that is at least two full fiscal years after the end of the PHE. This change is applicable on the effective date of this IFC.

Fiscal Year 2021 Proposed Medicare Payment and Policy Changes for Skilled Nursing Facilities (CMS-1737-P)

On April 10, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1737-P] for Fiscal Year (FY) 2021 that updates the Medicare payment rates and the quality programs for skilled nursing facilities (SNFs). CMS is publishing this proposed rule consistent with the legal requirements to update Medicare payment policies for skilled nursing facilities on an annual basis.  CMS recognizes that the entire healthcare system is focused on responding to the COVID-19 public health emergency. As a result, the proposed rule includes proposals required by statute and that affect Medicare payment to SNFs, as well as proposals that reduce provider burden and may help providers in the COVID-19 response.

These updates include routine technical rate-setting updates to the SNF PPS payment rates, as well as a proposal to adopt the most recent Office of Management and Budget (OMB) statistical area delineations and apply a 5 percent cap on wage index decreases from FY 2020 to FY 2021. We are also proposing changes to the ICD-10 code mappings that would be effective beginning in FY 2021, in response to stakeholder feedback. Finally, this rule includes minor administrative proposals related to the SNF Value-Based Purchasing (VBP) Program, further described below.

2019 Coronavirus (COVID-19) Outbreak:

The health and safety of America’s patients and provider workforce in the face of the Coronavirus Disease 2019 (COVID-19) outbreak is the top priority of the Trump Administration and CMS. We are working around the clock to equip the American healthcare system with maximum flexibility to respond to the 2019 Novel Coronavirus (COVID-19) pandemic. Recently, at President Trump’s direction, CMS issued an unprecedented array of temporary regulatory waivers and new rules to equip the American healthcare system with maximum flexibility to respond to the COVID-19 pandemic, including waiving the SNF benefit’s 3-day qualifying inpatient hospital stay requirement (pursuant to section 1812(f) of the Social Security Act), which allows SNF patients to be admitted without the typically required 3-day inpatient hospital stay and additional flexibility in relation to how beneficiaries may access a new SNF benefit period without the typical 60-day “wellness” period.

To keep up with the important work the Task Force is doing in response to COVID-19, go to Coronavirus.gov.  For information specific to CMS, please visit the Current Emergencies Website.

While CMS is focused on helping the healthcare system respond to the COVID-19 pandemic, we are releasing the annual Medicare payment rules as required by law to ensure providers are informed on the 2021 payment updates. This fact sheet discusses several major provisions of the proposed rule: the proposed changes to SNF payment policy under the SNF Prospective Payment System (PPS) and the SNF Value-Based Purchasing Program (VBP). This proposed rule includes proposals that would continue a commitment to shift Medicare payments from volume to value, with the continued implementation of the Patient Driven Payment Model (PDPM) and the SNF VBP, to improve program interoperability, operational quality and safety.

CMS encourages comments on this proposed rule and will accept comments until June 9, 2020.  The proposed rule [CMS-1737-P] can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection                                                                                                  

Strengthening Medicare

CMS projects aggregate payments to SNFs will increase by $784 million, or 2.3 percent, for FY 2021 compared to FY 2020. This estimated increase is attributable to a 2.7 percent market basket increase factor with a 0.4 percentage point reduction for multifactor productivity adjustment. 

As amended by section 4432 of the Balanced Budget Act of 1997 (BBA 1997) (Pub. L. 105-33, enacted on August 5, 1997), section 1888(e) of the Social Security Act (the Act) provides for the implementation of a PPS for SNFs.  This methodology uses prospective, case-mix adjusted per diem payment rates applicable to all covered SNF services defined in section 1888(e)(2)(A) of the Social Security Act.  The SNF PPS is effective for cost reporting periods beginning on or after July 1, 1998, and covers all costs of furnishing covered SNF services (routine, ancillary, and capital related costs) other than costs excluded under the statute, such as costs associated with approved educational activities and bad debts.

Changes in SNF PPS Wage Index

Under section 1888(e)(4)(G)(ii) of the Act, we adjust the federal rates to account for differences in area wage levels. We proposed to adopt revised geographic delineations provided by the Office of Management and Budget, which are used to identify a provider’s status as an urban or rural facility and to calculate the wage index and apply a 5 percent cap to wage index decreases.

Updates to PDPM Clinical Diagnosis Mappings

CMS’ Patient Driven Payment Model (PDPM) is an innovative and historic change in how we pay for care that is more focused on patient characteristics, rather than volume, under the SNF PPS and is used for classifying patients in a covered Medicare Part A SNF stay into case-mix groups.  Implemented on October 1, 2019, PDPM utilizes International Classification of Diseases, Version 10 (ICD-10) codes to classify SNF patients into payment groups. Each year, CMS considers recommendations from stakeholders on changes to the ICD-10 code mappings used under the PDPM. In this proposed rule, we are proposing changes to the ICD-10 code mappings that would be effective beginning in FY 2021, in response to these stakeholder recommendations. We encourage stakeholders to continue to provide this essential feedback on the ICD-10 code mappings, so that we may continue to improve and refine our payment methodology.

SNF Value-Based Purchasing (VBP) Program

The SNF VBP Program began distributing SNFs with incentive payments on October 1, 2018.  The SNF VBP Program scores SNFs on a single all-cause claims-based measure of hospital readmissions, as required by law, and adjusts Medicare Part A fee-for-service (FFS) payments under the SNF Prospective Payment System (PPS).  The Program aims to improve quality of care by incentivizing SNFs to reduce unplanned hospital readmissions. The law requires that CMS reduce SNFs’ Medicare Part A FFS payments by 2 percent, then redistribute between 50 to 70 percent of that reduction to SNFs as incentive payments.  Because of this legislative requirement, the Program results in Medicare savings. 

In the FY 2021 SNF PPS proposed rule, CMS is proposing to align the SNF VBP Program regulation text at 42 CFR § 413.338 with previously finalized policies, to apply the 30-day Phase One Review and Correction deadline to the baseline period quality measure quarterly report, and to establish performance periods and performance standards for upcoming program years.  CMS is not proposing to make any changes to the measures, SNF VBP scoring policies, or payment policies.

DATE: March 27, 2020

TO: MLN Connects Newsletter and Other Program-Specific Listserv Recipients

FROM: [Program-Specific Listservs, Partner Listservs (e.g., NHSN), ESRD Networks, CMS Emergency web page]

SUBJECT: Exceptions and Extensions for Quality Reporting Requirements for Acute Care Hospitals, PPS-Exempt Cancer Hospitals, Inpatient Psychiatric Facilities, Skilled Nursing Facilities, Home Health Agencies, Hospices, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, Ambulatory Surgical Centers, Renal Dialysis Facilities, and MIPS Eligible Clinicians Affected by COVID-19

The Centers for Medicare & Medicaid Services (CMS) is granting exceptions1 under certain Medicare quality reporting and value-based purchasing programs for acute care hospitals, Prospective Payment System (PPS)-exempt cancer hospitals, inpatient psychiatric facilities, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, longterm care hospitals, ambulatory surgical centers, renal dialysis facilities, and Merit-based Incentive Payment System (MIPS) eligible clinicians for all providers and suppliers participating in the programs described below across the United States and its territories in response to the 2019 Novel Coronavirus (COVID-19) pandemic.

On March 22, 2020, CMS announced relief for clinicians, providers, hospitals and facilities participating in quality reporting programs in response to COVID-19.2 This memorandum supplements and provides additional guidance to health care providers with regard to the announcement. The scope and duration of the exceptions under each Medicare quality reporting program and value-based purchasing program are described below. CMS is granting exceptions and extensions for certain deadlines to assist these health care providers while they direct their resources toward caring for their patients and ensuring the health and safety of patients and staff. In some instances, these exceptions and extensions are granted because the data collected may be greatly impacted by the response to COVID-19 and therefore should not be considered in the quality reporting program. CMS is closely monitoring the situation for potential adjustments and will update exception lists, exempted reporting periods, and submission deadlines accordingly as events occur.

Home Health Agencies (HHAs), Hospices, Inpatient Rehabilitation Facilities (IRFs), LongTerm Care Hospitals (LTCHs), and Skilled Nursing Facilities (SNFs)

CMS is granting an exception to the Quality Reporting Program (QRP) reporting requirements for all HHAs, Hospices, IRFs, LTCHs and SNFs. In accordance with 42 C.F.R. 412.560(c), 412.634(c), 413.360(c), 484.245(c), these providers are excepted from the reporting of data on measures, Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, and standardized patient assessment data required under these programs for the post-acute care (PAC) quality reporting programs for calendar years (CYs) 2019 and 2020 for the following quarters specific to each program:

• SNFs–Skilled Nursing Facility QRP
• October 1, 2019–December 31, 2019 (Q4 2019)
• January 1, 2020–March 31, 2020 (Q1 2020)
• April 1, 2020–June 30, 2020 (Q2 2020)

CMS finalized the SNF VBP Program’s Extraordinary Circumstances Exception (ECE) Policy in the FY 2019 SNF PPS final rule (83 FR 39280 through 39281). In accordance with § 413.338(d)(4)(iv) for the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program, CMS will exclude qualifying claims from the claims-based SNF 30-Day All-Cause Readmission Measure (SNFRM; NQF #2510) calculation for the following periods:

• January 1, 2020–March 31, 2020 (Q1 2020)
• April 1, 2020–June 30, 2020 (Q2 2020)

PAC QRP Extraordinary Circumstances Exception Request Information For further information about exceptions, view the program-specific web pages:

SNF Quality Reporting Reconsideration and Exception & Extension or email questions toSNFQRPReconsiderations@cms.hhs.gov

CMS is granting exceptions from reporting requirements and extensions for clinicians and providers participating in Medicare quality reporting programs with respect to upcoming measure reporting and data submission for those programs. These actions are part of CMS’s response to 2019 Novel Coronavirus (COVID-19).

Specifically, CMS is implementing additional extreme and uncontrollable circumstances policy exceptions and extensions for upcoming measure reporting and data submission deadlines that will impact both the SNF QRP and the SNF VBP.

CMS is delaying the Minimum Data Set (MDS) 3.0 v1.18.1 release, which had been scheduled for October 1, 2020, in response to stakeholder concerns. The MDS item sets are used by Nursing Home and Swing Bed providers to collect and submit patient data to CMS. This MDS data informs payment, quality, and the survey process.

In December of 2019, CMS posted a draft of the MDS 3.0 item set v1.18.0 and received feedback from our stakeholders.  We would like to thank the stakeholders for sharing their concerns regarding the proposed changes to the MDS 3.0 item sets and more specifically the removal of the Section G items from OBRA assessments.

The MDS changes CMS planned for October 1, 2020 will now be delayed.  CMS staff are actively engaged in discussions with various stakeholders, regarding the various changes, the impacts of these changes, as well as, the compressed timeline to educate and train facility staff and update software and IT systems.

Please direct any comments or questions regarding the above information to MDSCodinganswers@cms.hhs.gov mailbox

The Centers for Medicare & Medicaid Services (CMS) contracted with the RAND Corporation to identify and develop standardized patient assessment data elements (SPADEs) for use in the following post-acute care (PAC) patient assessment instruments: the Outcome and Assessment Information Set, used in home health agencies; the Inpatient Rehabilitation Facility Patient Assessment Instrument, used in inpatient rehabilitation facilities; the Long-Term Care Hospital Continuity Assessment Record and Evaluation Data Set, used in long-term care hospitals; and the Minimum Data Set, used in nursing homes and skilled nursing facilities. 

The Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual Version 3.0 has been posted. The Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual Version 3.0 contains detailed specifications for the assessment- and claims-based quality measures reported under the SNF QRP. The manual can be found below and the Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual Version 2.0 has been moved to the Quality Measures Archive page.