Does CMS Grasp How New Policies Will Burden Providers?

In the FY 2027 SNF PPS Final Rule, CMS finalized the Skilled Nursing Facility Quality Reporting Program (SNF QRP) All-Payer Reporting requirement. In the final rule, CMS acknowledged the additional burden of this policy but also noted several times that the benefits of collecting all-payer data outweigh the provider burden.

AAPACN directly asked CMS how this policy would be funded in its comments on the proposed rule, but this was not specifically addressed in CMS’s responses.

I found it concerning that CMS appeared to characterize the burden only in terms of the additional number of MDS items required but did not fully address the additional assessments needed or the efforts required to operationalize these changes.

If I were to break down the areas that will increase provider burden, I would put them into three major buckets: (1) new MDS items, (2) additional assessments, and (3) operational impact.

MDS Items

CMS has finalized adding three new items to the MDS, effective Oct. 1, 2029, for the FY 2031 SNF QRP program year. A mockup of the new items provides additional details. The first is an addition to A0310, where nurse assessment coordinators identify the assessment type. Questions have been added to indicate whether the assessment is for an “other skilled” admission or discharge. The next item, A1405, would indicate the primary payer for the resident, and A2405 would indicate when the “other skilled” stay started and ended. While completing three new items on the MDS does not seem significant, the decision-making and operational changes required to answer the questions may be overly burdensome to providers.

MDS Assessments

The second bucket, additional MDS assessments, was addressed in the SNF PPS Final Rule, but I am concerned that the estimated assessment burden may not account for all residents affected by this policy.

Under this policy, CMS would require two new assessments when a new admission or readmission that is not traditional Medicare Part A requires a skilled level of care. The “Other Skilled Care Admission Assessment” would be required at the start of the skilled stay, and the “Other Skilled Care Discharge Assessment” would be required at the end of the skilled stay.

In the proposed rule, CMS did not disclose how it calculated the estimated 1,133,649 additional MDS assessments required under the policy. Although CMS has access to the number and length of stay of Medicare Part A and Medicare Part C beneficiaries, it is unclear whether or how CMS estimated the number of residents with other payer types who would meet the skilled care criteria.

Operational Impact

The third bucket, the operational impact, is my greatest concern. This also was not well addressed in CMS’s responses in the final rule. I believe the main burden will come from identifying when the new assessments are needed, timely identification of payer types, monitoring skilled coverage, coordinating assessment timing, conducting interviews, completing Section GG assessments, and managing transitions between payers and levels of care.

This all takes time and resources from several interdisciplinary team members.

An Example

To illustrate what this may look like, consider a long-term care resident who has Medicaid only, requires hospitalization for an acute illness, and then returns to the SNF. Today, the facility team would determine whether the resident meets the criteria for a Significant Change in Status Assessment (SCSA), identify additional needs or services, such as therapy or additional assistance with activities of daily living, schedule the appropriate services and assessments, and update the care plan as indicated.

Under the All-Payer SNF QRP, when this resident is readmitted, the team will still need to determine whether a significant change has occurred, but it will also need to determine whether the resident meets the “other skilled” level of care. CMS has specified four criteria that must be met in the final rule. If these criteria are met, the team will need to schedule the new “Other Skilled Care Admission Assessment,” either in addition to or combined with the SCSA. The team would need to monitor the resident daily to ensure the skilled level of care continues to be met. The team would also need to plan for the end of the skilled stay to appropriately schedule and complete the “Other Skilled Care Discharge Assessment.”

To collect the SNF QRP-required data elements, this assessment is expected to be similar to the SNF PPS Discharge Assessment currently required at the end of a Medicare Part A stay. This means we would have to coordinate MDS scripted interviews, a three-day Section GG assessment, and many other MDS items at the end of the “other skilled” stay.

This scenario demonstrates many of the operational challenges providers will face under this policy. Oct. 1, 2029, is only two years away, but facilities have time to begin identifying gaps in their current processes—from timely identification of payer type to skilled level-of-care determinations. Over the next two years, facility leaders can strengthen the systems, workflows, and processes needed to address these gaps and better prepare for implementation of the new policy.

Jessie McGill, RN, BSN, RAC-MT, RAC-MT, is a regular contributor to Park Place, and is the curriculum development specialist for the American Association of Post-Acute Care Nursing.

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