On Aug. 11, 2025, Marc Zimmet stood onstage addressing the 1,500+ SNF professionals at his firm’s annual conference in Connecticut. His opening session covered a wide array of inconsistencies at the intersection of industry data and policy, and while his path from topic to topic seems random at first, there’s a common thread that pulls it all together. He’s as quick to criticize as he is to praise, so when his eyes grew wide as the Medicare cost report slide appeared onscreen, I figured one or the other was coming.

“CMS has been making more data available to the public than ever before, but when it comes to reimbursement, detailed information is limited to fee-for-service [FFS] beneficiaries. That leaves us in the dark for more than half the population. There is no hard data on recent Medicare Advantage [MA] SNF utilization and none on payment.”

He then explained the history, importance, and decay of the Medicare cost report. The annual filing is positioned as the ultimate “source of truth” for SNF financial matters, and while a long-overdue update was implemented for reporting periods ending on or after Sept. 30, 2025, CMS missed an opportunity to correct a quarter-century of neglect.

This is not a technical issue - it’s a curiosity. For decades, SNF days have been classified into three buckets: Medicare, Medicaid, and “Other” - aka, everyone else – but there’s another group that’s easy to overlook because it shouldn’t be there.

Zimmet continued, “The fourth classification is Title V [five]. We’ve prepared thousands of cost reports, and except for clerical errors, I’ve never seen a single day reported there, ever. I had to look it up. It’s a maternal and child health program, and a clear example of why the SNF cost report is not a modern dataset. CMS is trying to price and analyze contemporary dynamics through a form that still carries program categories from an era when cost reimbursement, distinct parts, state program alignment, and Title-based settlement logic mattered. That was decades ago.”

The ‘Elephant’

Shifting gears, he tied the inexplicable Title V issue to Medicare Advantage. “I’ve said for years that CMS need only change Title V to Medicare Advantage and we’d have data on the primary irritant rotting the SNF-economy. Even MedPAC couldn’t ignore the elephant in the business office anymore.”

That was the last time many expected to hear that complaint. Among other important changes, the updated cost report breaks Medicare utilization into FFS and Medicare Advantage. With MA identifiable as a standalone payer, analysts would be able to quantify the average MA per-diem rate for every facility and cleanly compare it to the FFS Medicare rate.

‘A-ha’

Then came the “a-ha” moment that connected issues that at first seemed disparate.

“The difference should open some eyes into how badly MA is underpaying facilities. Favorable Medicare rates have allowed Medicaid to pay below cost for decades, a process known as ‘cost shifting.’ The federal government subsidizes state long-term care funding. But MA is taking over and paying significantly less than FFS. That shrinks the subsidy, and the state must backfill revenue because the cost-shifting raft holds fewer beneficiaries each year. In fact, in many areas, the equation has already flipped. MA rates are so low that Medicaid is effectively subsidizing private insurance companies to keep SNFs afloat.”

He explained how much leverage the data could give SNFs in funding pleas and with the MA plans themselves, especially when it comes to weaving quality into reimbursement. Then suddenly he stopped talking; the expressive animation went still.

“That’s why it’s not going to happen. I can’t see it happening. CMS will find some way to blur the lines. We may see the days, but we won’t see the dollars, and someone will have to ask why.”

He pretty much nailed it. MA days are there, but the charges are “grossed up” and combined with “Other” revenue, meaning analysts can see MA utilization but still cannot isolate the actual MA dollars tied to those days.

I asked him what he thought when the first CMS Form 2540-24 filed reports were released, proving CMS’s calls for transparency don’t always go both ways.

“Some things never change,” he said. “Real MA data would be used against CMS and Medicaid in rate setting for the next decade. I wouldn’t want it out there if I was them. Much easier to leave Title V in place instead.”

This issue will be part of the broader discussion at Reimbursement Symphony this summer.

Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.