Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities: Revisions to Case-Mix Methodology

SUMMARY: We are issuing this advance notice of proposed rulemaking (ANPRM) to solicit public comments on potential options we may consider for revising certain aspects of the existing skilled nursing facility (SNF) prospective payment system (PPS) payment methodology to improve its accuracy, based on the results of our SNF Payment Models Research (SNF PMR) project. In particular, we are seeking comments on the possibility of replacing the SNF PPS' existing case-mix classification model, the Resource Utilization Groups, Version 4 (RUG-IV), with a new model, the Resident Classification System, Version I (RCS-I). We also discuss options for how such a change could be implemented, as well as a number of other policy changes we may consider to complement implementation of RCS-I.

EFFECTIVE DATE: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on June 26, 2017.

ADDRESSES: In commenting, please refer to file code CMS-1686-ANPRM. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of four ways (please choose only one of the ways listed):

1. Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Within the search bar, enter the Regulation Identifier Number associated with this regulation, 0938-AT17, and then click on the "Comment Now" box.

2. By regular mail. You may mail written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1686-ANPRM, P.O. Box 8016, Baltimore, MD 21244-8016.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By express or overnight mail. You may send written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1686-ANPRM, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

4. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments before the close of the comment period to either of the following addresses:

a. Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201.

(Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal Government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.)

b. Centers for Medicare & Medicaid Services, Department of Health and Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.

If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members.

Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: John Kane, (410) 786-0557.

SUPPLEMENTARY INFORMATION: Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to view public comments.

Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951.

To assist readers in referencing sections contained in this document, we are providing the following Table of Contents.

Table of Contents

I. Executive Summary

A. Purpose

B. Summary of Major Provisions

II. Background

A. Issues Relating to the Current Case Mix System for Payment of Skilled Nursing Facility Services Under Part A of the Medicare Program

B. Summary of the Skilled Nursing Facility Payment Models Research Project

III. Potential Revisions to SNF PPS Payment Methodology

A. Revisions to SNF PPS Base Federal Payment Rate Components

1. Background on SNF PPS Federal Base Payment Rates and Components

2. Data Sources Utilized for Revision of Federal Base Payment Rate Components

3. Methodology Used for the Calculation of Revised Federal Base Payment Rate Components

4. Updates and Wage Adjustments of Revised Federal Base Payment Rate Components

B. Potential Design and Methodology for Case-Mix Adjustment of Federal Rates

1. Background on Resident Classification System, Version I

2. Data Sources Utilized for Developing RCS-I

a. Medicare Enrollment Data

b. Medicare Claims Data

c. Assessment Data

d. Facility Data

3. Resident Classification Under RCS-I

a. Background

b. Physical and Occupational Therapy Case-Mix Classification

c. Speech-Language Pathology Case-Mix Classification

d. Nursing Case-Mix Classification

e. Non-Therapy Ancillary Case-Mix Classification

f. Payment Classifications under RCS-I

4. Variable Per Diem Adjustment Factors and Payment Schedule

C. Use of the Resident Assessment Instrument--Minimum Data Set, Version 3

1. Potential Revisions to Minimum Data Set (MDS) Completion Schedule

2. Potential Revisions to Therapy Provision Policies Under the SNF PPS

3. Interrupted Stay Policy

D. Relationship of RCS-I to Existing Skilled Nursing Facility Level of Care Criteria

E. Effect of RCS-I on Temporary AIDS Add-on Payment

F. Potential Impacts of Implementing RCS-I

IV. Collection of Information Requirements

V. Response to Comments

Acronyms

In addition, because of the many terms to which we refer by acronym in this ANPRM, we are listing these abbreviations and their corresponding terms in alphabetical order below:

AIDS Acquired Immune Deficiency Syndrome

ARD Assessment reference date

BBRA Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, Public Law 106-113

CASPER Certification and Survey Provider Enhanced Reporting

CCN CMS Certification Number

CFR Code of Federal Regulations

CMI Case-mix index

CMS Centers for Medicare & Medicaid Services

FR Federal Register

FY Fiscal year

ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification

IPPS Inpatient prospective payment system

IRF Inpatient Rehabilitation Facility

IRF-PAI Inpatient Rehabilitation Facility Patient Assessment Instrument

LTCH Long-term care hospital

MDS Minimum data set

MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173

NF Nursing facility

NTA Non-therapy ancillary

OASIS Outcome and Assessment Information Set

OMB Office of Management and Budget

PAC Post-acute care

PPS Prospective Payment System

QIES Quality Improvement and Evaluation System

QIES ASAP Quality Improvement and Evaluation System Assessment Submission and Processing

RAI Resident assessment instrument

RCS-I Resident Classification System, Version I

RFA Regulatory Flexibility Act, Public Law 96-354

RIA Regulatory impact analysis

RUG-III Resource Utilization Groups, Version 3

RUG-IV Resource Utilization Groups, Version 4

RUG-53 Refined 53-Group RUG-III Case-Mix Classification System

SNF Skilled nursing facility

SNF PMR Skilled Nursing Facility Payment Models Research

STM Staff time measurement

STRIVE Staff time and resource intensity verification

TEP Technical expert panel

I. Executive Summary

A. Purpose

--This is a summary of a Federal Register article originally published on the page number listed below--

Advance notice of proposed rulemaking with comment.

CFR Part: "42 CFR Parts 409 and 488"

RIN Number: "RIN 0938-AT17"

Citation: "82 FR 20980"

Document Number: "CMS-1686-ANPRM"

Federal Register Page Number: "20980"

"Proposed Rules"