Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2015
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Final rule.
CFR Part: "42 CFR Part 488"
RIN Number: "RIN 0938-AS07"
Citation: "79 FR 45628"
Document Number: "CMS-1605-F"
"Rules and Regulations"
SUMMARY: This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2015. In addition, it adopts the most recent
EFFECTIVE DATE: Effective Date: This final rule is effective on
FOR FURTHER INFORMATION CONTACT:
Penny Gershman, (410) 786-6643, for information related to clinical issues.
John Kane, (410) 786-0557, for information related to the development of the payment rates and case-mix indexes.
Kia Sidbury, (410) 786-7816, for information related to the wage index.
Karen Tritz, (410) 786-8021, for information related to Civil Money Penalties.
Bill Ullman, (410) 786-5667, for information related to level of care determinations, consolidated billing, and general information.
SUPPLEMENTARY INFORMATION:
Availability of Certain Tables Exclusively Through the Internet on the CMS Web Site
In the past, tables setting forth the Wage Index for Urban Areas Based on CBSA Labor Market Areas and the Wage Index Based on CBSA Labor Market Areas for Rural Areas were published in the
Readers who experience any problems accessing any of the tables that are posted on the CMS Web site identified above should contact
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
C. Summary of Impacts
II. Background
A. Statutory Basis and Scope
B. Initial Transition
C. Required Annual Rate Updates
III. Summary of the Provisions of the FY 2015 SNF PPS Proposed Rule
IV. Analysis of and Responses to Public Comments on the FY 2015 SNF PPS Proposed Rule
A. General Comments on the FY 2015 SNF PPS Proposed Rule
B. SNF PPS Rate Setting Methodology and FY 2015 Update
1. Federal Base Rates
2. SNF Market Basket Update
a. SNF Market Basket Index
b. Use of the SNF Market Basket Percentage
c. Forecast Error Adjustment
d. Multifactor Productivity Adjustment
i. Incorporating the Multifactor Productivity Adjustment Into the Market Basket Update
e. Market Basket Update Factor for FY 2015
3. Case-Mix Adjustment
4. Wage Index Adjustment
5. Adjusted Rate Computation Example
C. Additional Aspects of the SNF PPS
1. SNF Level of Care--Administrative Presumption
2. Consolidated Billing
3. Payment for SNF-Level Swing-Bed Services
D. Other Issues
1. Changes to the SNF PPS Wage Index
a. Labor-Related Share
2.
3. Revisions to Policies Related to the Change of Therapy (COT) Other Medicare Required Assessment (OMRA)
4. Civil Money Penalties (section 6111 of the Affordable Care Act)
5. Observations on Therapy Utilization Trends
6. Accelerating Health Information Exchange in the SNF PPS
7. SNF Value Based Purchasing
V. Provisions of the Final Rule; Regulations Text
VI. Collection of Information Requirements
VII. Economic Analyses
Regulations Text
Acronyms
In addition, because of the many terms to which we refer by acronym in this final rule, we are listing these abbreviations and their corresponding terms in alphabetical order below:
AIDS Acquired Immune Deficiency Syndrome
ARD Assessment reference date
BBA Balanced Budget Act of 1997, Public Law 105-33
BBRA Medicare,
BIPA Medicare,
CAH Critical access hospital
CBSA Core-based statistical area
CFR Code of Federal Regulations
CMI Case-mix index
COT Change of therapy
EHR Electronic health record
EOT End of therapy
FQHC Federally qualified health center
FY Fiscal year
GAO
HCPCS Healthcare Common Procedure Coding System
HOMER Home office
ICR Information Collection Requirements
IGI IHS (Information Handling Services)
IPPS Inpatient Prospective Payment System
MDS Minimum data set
MFP Multifactor productivity
MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173
MSA Metropolitan statistical area
NAICS North American Industrial Classification System
NF Nursing facility
OMRA Other Medicare Required Assessment
PAMA Protecting Access to Medicare Act of 2014, Public Law 113-93
PPS Prospective Payment System
RAI Resident assessment instrument
RAVEN Resident assessment validation entry
RFA Regulatory Flexibility Act, Public Law 96-354
RHC Rural health clinic
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
SCHIP State Children's Health Insurance Program
SNF Skilled nursing facility
STM Staff time measurement
STRIVE Staff time and resource intensity verification
UMRA Unfunded Mandates Reform Act, Public Law 104-4
I. Executive Summary
A. Purpose
This final rule updates the SNF prospective payment rates for FY 2015 as required under section 1888(e)(4)(E) of the Act. It also responds to section 1888(e)(
B. Summary of Major Provisions
In accordance with sections 1888(e)(4)(E)(ii)(IV) and 1888(e)(5) of the Act, the federal rates in this final rule reflect an update to the rates that we published in the SNF PPS final rule for FY 2014 (78 FR 47936) which reflects the SNF market basket index, adjusted by the forecast error correction, if applicable, and the multifactor productivity adjustment for FY 2015.
C. Summary of Impacts GOES
Provision Total transfers description FY 2015 SNF PPS payment rate update The overall economic impact of this final rule is an estimated increase of$750 million in aggregate payments to SNFs during FY 2015.
II. Background
A. Statutory Basis and Scope
As amended by section 4432 of the Balanced Budget Act of 1997 (BBA, Pub. L. 105-33, enacted on
As noted in section I.F. of that legislative history, on
B. Initial Transition
Under sections 1888(e)(1)(A) and 1888(e)(11) of the Act, the SNF PPS included an initial, three-phase transition that blended a facility-specific rate (reflecting the individual facility's historical cost experience) with the federal case-mix adjusted rate. The transition extended through the facility's first three cost reporting periods under the PPS, up to and including the one that began in FY 2001. Thus, the SNF PPS is no longer operating under the transition, as all facilities have been paid at the full federal rate effective with cost reporting periods beginning in FY 2002. As we now base payments for SNFs entirely on the adjusted federal per diem rates, we no longer include adjustment factors under the transition related to facility-specific rates for the upcoming FY.
C. Required Annual Rate Updates
Section 1888(e)(4)(E) of the Act requires the SNF PPS payment rates to be updated annually. The most recent annual update occurred in a final rule that set forth updates to the SNF PPS payment rates for FY 2014 (78 FR 47936,
Section 1888(e)(
* The unadjusted federal per diem rates to be applied to days of covered SNF services furnished during the upcoming FY.
* The case-mix classification system to be applied for these services during the upcoming FY.
* The factors to be applied in making the area wage adjustment for these services.
Along with other revisions discussed later in this preamble, this final rule provides the required annual updates to the per diem payment rates for SNFs for FY 2015.
III. Summary of the Provisions of the FY 2015 SNF PPS Proposed Rule
In the FY 2014 SNF PPS proposed rule (79 FR 25767), we proposed an update to the payment rates used under the PPS for SNFs for FY 2015. In addition, we proposed to adopt the most recent OMB statistical area delineations to identify a facility's urban or rural status for the purpose of determining which set of rate tables would apply to the facility, and to determine the SNF PPS wage index including a proposed 1-year transition with a blended wage index for all providers for FY 2015. It also included a discussion of the SNF therapy payment research currently underway within CMS. The proposed rule also proposed a revision to policies related to the COT OMRA. The proposed rule included a discussion of a provision related to the Affordable Care Act involving Civil Money Penalties. Finally, the proposed rule included a discussion of observed trends related to therapy utilization among SNF providers and a discussion of accelerating health information exchange in SNFs.
IV. Analysis of and Responses to Public Comments on the FY 2015 SNF PPS Proposed Rule
In response to the publication of the FY 2015 SNF PPS proposed rule, we received 26 timely public comments from individuals, providers, corporations, government agencies, private citizens, trade associations, and major organizations. The following are brief summaries of each proposed provision, a summary of the public comments that we received related to that proposal, and our responses to the comments.
A. General Comments on the FY 2015 SNF PPS Proposed Rule
In addition to the comments we received on the proposed rule's discussion of specific aspects of the SNF PPS (which we address later in this final rule), commenters also submitted the following, more general observations on the payment system. A discussion of these comments, along with our responses, appears below.
Comment: We received a few comments about the operational aspects of updating the subregulatory guidance contained in the MDS RAI manual, including the frequency of updates and process for announcing revisions. These commenters stated that CMS has made major revisions to the RAI manual with little or no notice to providers and without meaningful consultation with stakeholders. These commenters further stated that CMS should utilize a more formal process for announcing revisions and reinterpretations of the RAI manual.
Response: We appreciate the commenters' suggestions and we recognize that the MDS 3.0 is a complex assessment tool. We have provided education, clarification and training associated with the MDS 3.0, as well as discussion of potential revisions and updates to the RAI manual, at national training conferences, and postings to the MDS 3.0 and SNF PPS Web site. We also provide support to and consult with stakeholders through oral and written inquiries and, most notably, through our regular and special Open Door Forums. We are committed to continuing training on the MDS 3.0 and to ensuring that the update process is predictable for providers and gives providers sufficient notice of and time to discuss, incorporate and train on any revisions to the manual which may occur. We will take the commenters' suggestions into consideration for future operational enhancements.
Comment: Several commenters raised concerns regarding the compensation for Non-Therapy Ancillaries (NTAs), specifically for hospital-based SNFs within the SNF PPS. These commenters urged CMS to expedite the research necessary to develop a new model for NTA payment and to implement such a model shortly thereafter.
Response: We appreciate the comments on this topic and the broad support for our research efforts on the development of a new NTA payment model. Furthermore, the comments we received provided a number of interesting and creative ideas for future consideration. We look forward to working with providers and stakeholders in the future as we continue to research possible refinements to address concerns with the SNF PPS, such as the SNF therapy research work discussed in section IV.D.2 of this final rule.
Comment: One commenter recommended that we address the need for CMS to broaden the categories of healthcare professionals who may order patient diets. The commenter stated that such a change will improve patient health and allows SNFs to respond more quickly to resident nutritional needs.
Response: We appreciate this comment, but note that the specific issues the commenter raised about who, within a SNF, may prescribe resident diets relate to the certification standards for long-term care facilities, and therefore, are beyond the scope of this final rule. We have, however, shared this comment with CMS's survey and certification staff so that they can consider these suggestions as part of their ongoing review and refinement of our policies.
Comment: One commenter supported CMS's proposal to include several new outcomes measures as part of the FY 2017 Hospital Value-Based Purchasing program.
Response: We appreciate this comment, but note that this comment does not relate to the SNF PPS and involves a program that does not apply to SNFs. We have, however, shared this comment with CMS staff who work more closely with the Hospital Value-Based Purchasing program to consider as part of their ongoing review and refinement of their proposed policies.
B. SNF PPS Rate Setting Methodology and FY 2015 Update
In the FY 2015 SNF PPS proposed rule (79 FR 25770 through 25779), we outlined the basic methodology used to set the rates for the SNF PPS. We also discussed a proposal associated with our rate setting methodology, specifically a proposal to adopt the most recent
1. Federal Base Rates
Under section 1888(e)(4) of the Act, the SNF PPS uses per diem federal payment rates based on mean SNF costs in a base year (FY 1995) updated for inflation to the first effective period of the PPS. We developed the federal payment rates using allowable costs from hospital-based and freestanding SNF cost reports for reporting periods beginning in FY 1995. The data used in developing the federal rates also incorporated a "Part B add-on," which is an estimate of the amounts that, prior to the SNF PPS, would have been payable under Part B for covered SNF services furnished to individuals during the course of a covered Part A stay in a SNF.
In developing the rates for the initial period, we updated costs to the first effective year of the PPS (the 15-month period beginning
2. SNF Market Basket Update
a. SNF Market Basket Index
Section 1888(e)(5)(A) of the Act requires us to establish a SNF market basket index that reflects changes over time in the prices of an appropriate mix of goods and services included in covered SNF services. Accordingly, we have developed a SNF market basket index that encompasses the most commonly used cost categories for SNF routine services, ancillary services, and capital-related expenses. We use the SNF market basket index, adjusted in the manner described below, to update the federal rates on an annual basis. In the SNF PPS final rule for FY 2014 (78 FR 47939 through 47946), we revised and rebased the market basket, which included updating the base year from FY 2004 to FY 2010.
For the FY 2015 final rule, the FY 2010-based SNF market basket growth rate is estimated to be 2.5 percent, which is based on the
b. Use of the SNF Market Basket Percentage
Section 1888(e)(5)(B) of the Act defines the SNF market basket percentage as the percentage change in the SNF market basket index from the midpoint of the previous FY to the midpoint of the current FY. For the federal rates set forth in this final rule, we use the percentage change in the SNF market basket index to compute the update factor for FY 2015. This is based on the IGI second quarter 2014 forecast (with historical data through the first quarter 2014) of the FY 2015 percentage increase in the FY 2010-based SNF market basket index for routine, ancillary, and capital-related expenses, which is used to compute the update factor in this final rule. As discussed in sections IV.B.2.c. and IV.B.2.d. of this final rule, this market basket percentage change would be reduced by the forecast error correction (as described in
c. Forecast Error Adjustment
As discussed in the
For FY 2013 (the most recently available FY for which there is final data), the estimated increase in the market basket index was 2.5 percentage points, while the actual increase for FY 2013 was 2.2 percentage points, resulting in the actual increase being 0.3 percentage point lower than the estimated increase. Accordingly, as the difference between the estimated and actual amount of change in the market basket index does not exceed the 0.5 percentage point threshold, the payment rates for FY 2015 do not include a forecast error adjustment. Table 1 shows the forecasted and actual market basket amounts for FY 2013. GOES
Table 1--Difference Between the Forecasted and Actual Market Basket Increases for FY 2013 Index Forecasted Actual FY 2013 FY 2013 FY 2013 difference increase * increase ** SNF 2.5 2.2 -0.3 * Published inFederal Register ; based on second quarter 2012 IGI forecast (2004-based index). ** Based on the second quarter 2014IHS Global Insight forecast, with historical data through the first quarter 2014 (2004-based index).
d. Multifactor Productivity Adjustment
Section 3401(b) of the Affordable Care Act requires that, in FY 2012 (and in subsequent FYs), the market basket percentage under the SNF payment system as described in section 1888(e)(5)(B)(i) of the Act is to be reduced annually by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II) of the Act. Section 1886(b)(3)(B)(xi)(II) of the Act, added by section 3401(a) of the Affordable Care Act, sets forth the definition of this productivity adjustment. The statute defines the productivity adjustment to be equal to "the 10-year moving average of changes in annual economy-wide private nonfarm business multi-factor productivity (as projected by the Secretary for the 10-year period ending with the applicable fiscal year, year, cost-reporting period, or other annual period)" (the MFP adjustment).
The projection of MFP is currently produced by IGI, an economic forecasting firm. To generate a forecast of MFP, IGI replicated the MFP measure calculated by the BLS, using a series of proxy variables derived from IGI's U.S. macroeconomic models. This process is described in greater detail in section III.F.3. of the FY 2012 SNF PPS final rule (76 FR 48527 through 48529).
i. Incorporating the Multifactor Productivity Adjustment Into the Market Basket Update
According to section 1888(e)(5)(A) of the Act, the Secretary "shall establish a skilled nursing facility market basket index that reflects changes over time in the prices of an appropriate mix of goods and services included in covered skilled nursing facility services." Section 1888(e)(5)(B)(ii) of the Act, added by section 3401(b) of the Affordable Care Act, requires that for FY 2012 and each subsequent FY, after determining the market basket percentage described in section 1888(e)(5)(B)(i) of the Act, "the Secretary shall reduce such percentage by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II)" (which we refer to as the MFP adjustment). Section 1888(e)(5)(B)(ii) of the Act further states that the reduction of the market basket percentage by the MFP adjustment may result in the market basket percentage being less than zero for a FY, and may result in payment rates under section 1888(e) of the Act for a FY being less than such payment rates for the preceding FY. Thus, if the application of the MFP adjustment to the market basket percentage calculated under section 1888(e)(5)(B)(i) of the Act results in an MFP-adjusted market basket percentage that is less than zero, then the annual update to the unadjusted federal per diem rates under section 1888(e)(4)(E)(ii) of the Act would be negative, and such rates would decrease relative to the prior FY.
For the FY 2015 update, the MFP adjustment is calculated as the 10-year moving average of changes in MFP for the period ending
e. Market Basket Update Factor for FY 2015
Sections 1888(e)(4)(E)(ii)(IV) and 1888(e)(5)(i) of the Act require that the update factor used to establish the FY 2015 unadjusted federal rates be at a level equal to the market basket index percentage change. Accordingly, we determined the total growth from the average market basket level for the period of
We proposed in the FY 2015 SNF PPS proposed rule (79 FR 25772) that while we would continue to compute and apply separate federal per diem rates for SNFs located in urban and rural areas as we have in the past, beginning on
$G*5_*Table 2--FY 2015 Unadjusted Federal Rate perDiem Urban Rate component Nursing--case- Therapy--case- Therapy--non- Non-case-mix mix mix case-mix Per Diem$169.28 $127.51 $16.79 $86.39 Amount
Table 3--FY 2015 Unadjusted Federal Rate per Diem Rural Rate component Nursing--case- Therapy--case- Therapy--non- Non-case-mix mix mix case-mix Per Diem$161.72 $147.02 $17.94 $87.99 Amount
3. Case-Mix Adjustment
Under section 1888(e)(4)(G)(i) of the Act, the federal rate also incorporates an adjustment to account for facility case-mix, using a classification system that accounts for the relative resource utilization of different patient types. The statute specifies that the adjustment is to reflect both a resident classification system that the Secretary establishes to account for the relative resource use of different patient types, as well as resident assessment data and other data that the Secretary considers appropriate. In the interim final rule with comment period that initially implemented the SNF PPS (63 FR 26252,
We note that case-mix classification is based, in part, on the beneficiary's need for skilled nursing care and therapy services. The case-mix classification system uses clinical data from the MDS to assign a case-mix group to each patient that is then used to calculate a per diem payment under the SNF PPS. As discussed in section IV.C.1. of this final rule, the clinical orientation of the case-mix classification system supports the SNF PPS's use of an administrative presumption that considers a beneficiary's initial case-mix classification to assist in making certain SNF level of care determinations. Further, because the MDS is used as a basis for payment, as well as a clinical assessment, we have provided extensive training on proper coding and the time frames for MDS completion in our Resident Assessment Instrument (RAI) Manual. For an MDS to be considered valid for use in determining payment, the MDS assessment must be completed in compliance with the instructions in the RAI Manual in effect at the time the assessment is completed. For payment and quality monitoring purposes, the RAI Manual consists of both the Manual instructions and the interpretive guidance and policy clarifications posted on the appropriate MDS Web site at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html.
In addition, we note that section 511 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA, Pub. L. 108-173) amended section 1888(e)(12) of the Act to provide for a temporary increase of 128 percent in the PPS per diem payment for any SNF residents with Acquired Immune Deficiency Syndrome (AIDS), effective with services furnished on or after
Currently, we use the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) code 042 to identify those residents for whom it is appropriate to apply the AIDS add-on established by section 511 of the MMA. In this context, we note that the Department published a final rule in the
However, on
Under section 1888(e)(
Table 4--RUG-IV Case-Mix Adjusted Federal Rates and Associated Indexes Urban RUG-IV Nursing Therapy Nursing Therapy Non-case Non-case Total category index index component component mix mix rate therapy component comp RUX 2.67 1.87$451.98 $238.44 $86.39 $776.81 RUL 2.57 1.87 435.05 238.44 86.39 759.88 RVX 2.61 1.28 441.82 163.21 86.39 691.42 RVL 2.19 1.28 370.72 163.21 86.39 620.32 RHX 2.55 0.85 431.66 108.38 86.39 626.43 RHL 2.15 0.85 363.95 108.38 86.39 558.72 RMX 2.47 0.55 418.12 70.13 86.39 574.64 RML 2.19 0.55 370.72 70.13 86.39 527.24 RLX 2.26 0.28 382.57 35.70 86.39 504.66 RUC 1.56 1.87 264.08 238.44 86.39588.91 RUB 1.56 1.87 264.08 238.44 86.39 588.91 RUA 0.99 1.87 167.59 238.44 86.39 492.42 RVC 1.51 1.28 255.61 163.21 86.39 505.21 RVB 1.11 1.28 187.90 163.21 86.39 437.50 RVA 1.10 1.28 186.21 163.21 86.39 435.81 RHC 1.45 0.85 245.46 108.38 86.39 440.23 RHB 1.19 0.85 201.44 108.38 86.39 396.21 RHA 0.91 0.85 154.04 108.38 86.39 348.81 RMC 1.36 0.55 230.22 70.13 86.39386.74 RMB 1.22 0.55 206.52 70.13 86.39 363.04 RMA 0.84 0.55 142.20 70.13 86.39 298.72 RLB 1.50 0.28 253.92 35.70 86.39 376.01 RLA 0.71 0.28 120.19 35.70 86.39 242.28 ES3 3.58 606.02$16.79 86.39 709.20 ES2 2.67 451.98 16.79 86.39 555.16 ES1 2.32 392.73 16.79 86.39 495.91 HE2 2.22 375.80 16.79 86.39 478.98 HE1 1.74 294.55 16.79 86.39 397.73 HD2 2.04 345.33 16.79 86.39 448.51 HD1 1.60 270.85 16.79 86.39 374.03 HC2 1.89 319.94 16.79 86.39 423.12 HC1 1.48 250.53 16.79 86.39 353.71 HB2 1.86 314.86 16.79 86.39 418.04 HB1 1.46 247.15 16.79 86.39 350.33 LE2 1.96 331.79 16.79 86.39 434.97 LE1 1.54 260.69 16.79 86.39 363.87 LD2 1.86 314.86 16.79 86.39 418.04 LD1 1.46 247.15 16.79 86.39 350.33 LC2 1.56 264.08 16.79 86.39 367.26 LC1 1.22 206.52 16.79 86.39 309.70 LB2 1.45 245.46 16.79 86.39 348.64 LB1 1.14 192.98 16.79 86.39 296.16 CE2 1.68 284.39 16.79 86.39 387.57 CE1 1.50 253.92 16.79 86.39 357.10 CD2 1.56 264.08 16.79 86.39 367.26 CD1 1.38 233.61 16.79 86.39 336.79 CC2 1.29 218.37 16.79 86.39 321.55 CC1 1.15 194.67 16.79 86.39 297.85 CB2 1.15 194.67 16.79 86.39 297.85 CB1 1.02 172.67 16.79 86.39 275.85 CA2 0.88 148.97 16.79 86.39 252.15 CA1 0.78 132.04 16.79 86.39 235.22 BB2 0.97 164.20 16.79 86.39 267.38 BB1 0.90 152.35 16.79 86.39 255.53 BA2 0.70 118.50 16.79 86.39 221.68 BA1 0.64 108.34 16.79 86.39 211.52 PE2 1.50 253.92 16.79 86.39 357.10 PE1 1.40 236.99 16.79 86.39 340.17 PD2 1.38 233.61 16.79 86.39 336.79 PD1 1.28 216.68 16.79 86.39 319.86 PC2 1.10 186.21 16.79 86.39 289.39 PC1 1.02 172.67 16.79 86.39 275.85 PB2 0.84 142.20 16.79 86.39 245.38 PB1 0.78 132.04 16.79 86.39 235.22 PA2 0.59 99.88 16.79 86.39 203.06 PA1 0.54 91.41 16.79 86.39 194.59
Table 5--RUG-IV Case-Mix Adjusted Federal Rates and Associated Indexes Rural RUG-IV Nursing Therapy Nursing Therapy Non-case Non-case Total category index index component component mix mix rate therapy component comp RUX 2.67 1.87$431.79 $274.93 $87.99 $794.71 RUL 2.57 1.87 415.62 274.93 87.99 778.54 RVX 2.61 1.28 422.09 188.19 87.99 698.27 RVL 2.19 1.28 354.17 188.19 87.99 630.35 RHX 2.55 0.85 412.39 124.97 87.99 625.35 RHL 2.15 0.85 347.70 124.97 87.99 560.66 RMX 2.47 0.55 399.45 80.86 87.99 568.30 RML 2.19 0.55 354.17 80.86 87.99 523.02 RLX 2.26 0.28 365.49 41.17 87.99 494.65 RUC 1.56 1.87 252.28 274.93 87.99615.20 RUB 1.56 1.87 252.28 274.93 87.99 615.20 RUA 0.99 1.87 160.10 274.93 87.99 523.02 RVC 1.51 1.28 244.20 188.19 87.99 520.38 RVB 1.11 1.28 179.51 188.19 87.99 455.69 RVA 1.10 1.28 177.89 188.19 87.99 454.07 RHC 1.45 0.85 234.49 124.97 87.99 447.45 RHB 1.19 0.85 192.45 124.97 87.99 405.41 RHA 0.91 0.85 147.17 124.97 87.99 360.13 RMC 1.36 0.55 219.94 80.86 87.99388.79 RMB 1.22 0.55 197.30 80.86 87.99 366.15 RMA 0.84 0.55 135.84 80.86 87.99 304.69 RLB 1.50 0.28 242.58 41.17 87.99 371.74 RLA 0.71 0.28 114.82 41.17 87.99 243.98 ES3 3.58 578.96 17.94 87.99 684.89 ES2 2.67 431.79 17.94 87.99 537.72 ES1 2.32 375.19 17.94 87.99 481.12 HE2 2.22 359.02 17.94 87.99 464.95 HE1 1.74 281.39 17.94 87.99 387.32 HD2 2.04 329.91 17.94 87.99 435.84 HD1 1.60 258.75 17.94 87.99 364.68 HC2 1.89 305.65 17.94 87.99 411.58 HC1 1.48 239.35 17.94 87.99 345.28 HB2 1.86 300.80 17.94 87.99 406.73 HB1 1.46 236.11 17.94 87.99 342.04 LE2 1.96 316.97 17.94 87.99 422.90 LE1 1.54 249.05 17.94 87.99 354.98 LD2 1.86 300.80 17.94 87.99 406.73 LD1 1.46 236.11 17.94 87.99 342.04 LC2 1.56 252.28 17.94 87.99 358.21 LC1 1.22 197.30 17.94 87.99 303.23 LB2 1.45 234.49 17.94 87.99 340.42 LB1 1.14 184.36 17.94 87.99 290.29 CE2 1.68 271.69 17.94 87.99 377.62 CE1 1.50 242.58 17.94 87.99 348.51 CD2 1.56 252.28 17.94 87.99 358.21 CD1 1.38 223.17 17.94 87.99 329.10 CC2 1.29 208.62 17.94 87.99 314.55 CC1 1.15 185.98 17.94 87.99 291.91 CB2 1.15 185.98 17.94 87.99 291.91 CB1 1.02 164.95 17.94 87.99 270.88 CA2 0.88 142.31 17.94 87.99 248.24 CA1 0.78 126.14 17.94 87.99 232.07 BB2 0.97 156.87 17.94 87.99 262.80 BB1 0.90 145.55 17.94 87.99 251.48 BA2 0.70 113.20 17.94 87.99 219.13 BA1 0.64 103.50 17.94 87.99 209.43 PE2 1.50 242.58 17.94 87.99 348.51 PE1 1.40 226.41 17.94 87.99 332.34 PD2 1.38 223.17 17.94 87.99 329.10 PD1 1.28 207.00 17.94 87.99 312.93 PC2 1.10 177.89 17.94 87.99 283.82 PC1 1.02 164.95 17.94 87.99 270.88 PB2 0.84 135.84 17.94 87.99 241.77 PB1 0.78 126.14 17.94 87.99 232.07 PA2 0.59 95.41 17.94 87.99 201.34 PA1 0.54 87.33 17.94 87.99 193.26
4. Wage Index Adjustment
Section 1888(e)(4)(G)(ii) of the Act requires that we adjust the federal rates to account for differences in area wage levels, using a wage index that the Secretary determines appropriate. Since the inception of the SNF PPS, we have used hospital inpatient wage data in developing a wage index to be applied to SNFs. In the FY 2015 SNF PPS proposed rule (79 FR 25775), we proposed to continue this practice for FY 2015, as we continue to believe that in the absence of SNF-specific wage data, using the hospital inpatient wage index data is appropriate and reasonable for the SNF PPS. As explained in the update notice for FY 2005 (69 FR 45786), the SNF PPS does not use the hospital area wage index's occupational mix adjustment, as this adjustment serves specifically to define the occupational categories more clearly in a hospital setting; moreover, the collection of the occupational wage data also excludes any wage data related to SNFs. Therefore, we believe that using the updated hospital inpatient wage data exclusive of the occupational mix adjustment continues to be appropriate for SNF payments. For FY 2015, the updated wage data are for hospital cost reporting periods beginning on or after
We note that section 315 of the
In the FY 2015 SNF PPS proposed rule (79 FR 25775 through 25776), we also proposed to continue to use the same methodology discussed in the SNF PPS final rule for FY 2008 (72 FR 43423) to address those geographic areas in which there are no hospitals, and thus, no hospital wage index data on which to base the calculation of the FY 2015 SNF PPS wage index. For rural geographic areas that do not have hospitals and, therefore, lack hospital wage data on which to base an area wage adjustment, we would use the average wage index from all contiguous Core-Based Statistical Areas (CBSAs) as a reasonable proxy. For FY 2015, there are no rural geographic areas without hospitals for which we would apply this policy. For rural
A discussion of the general comments that we received on the wage index adjustment to the federal rates, and our responses to those comments, appears below. Comments on the specific proposal to use revised OMB delineations as part of the wage index are discussed in section IV.D.1. of this final rule.
Comment: Several commenters stated that hospital cost data may not be the most reliable resource when determining geographical differences in salary structure for skilled nursing facilities. These commenters also stated that, if CMS plans to continue using hospital cost data as the basis of SNF wage index adjustments, then CMS should consider adopting certain wage index policies in use under the IPPS, such as reclassification, because SNFs compete in a similar labor pool as acute care hospitals. Commenters stated that even if reclassification is not permissible, CMS should consider using the post-reclassification hospital wage data to influence SNF PPS wage index policy decisions. In addition, a few commenters recommended that CMS develop a SNF-specific wage index. Finally, a few commenters recommended that CMS attempt to smooth out the perceived volatility of annual wage index changes by implementing a floor and ceiling for annual changes to the wage index that are above or below a certain level.
Response: Consistent with our previous responses to these recurring comments (most recently published in the FY 2014 SNF PPS final rule (78 FR 47952)), developing a wage index that utilizes data specific to SNFs would require us to engage in a resource-intensive audit process. Also, we note that section 315 of BIPA authorized us to establish a geographic reclassification procedure that is specific to SNFs, but only after collecting the data necessary to establish a SNF-specific wage index that is based on wage data from nursing homes. However, to date, this has proven to be unfeasible due to the volatility of existing SNF wage data and the significant amount of resources that would be required to improve the quality of that data. Furthermore, we believe the collection of SNF-specific wage data would place a significant amount of additional burden on SNFs. As discussed above, we continue to believe that in the absence of SNF-specific wage data, using the pre-reclassified hospital inpatient wage data (without the occupational mix adjustment) is appropriate and reasonable for the SNF PPS. Additionally, we believe that using post-reclassification inpatient hospital wage data to influence SNF PPS wage index policy decisions, as suggested by commenters, would not be appropriate as such reclassification data are specific to those hospitals making that request, which may or may not apply to a given SNF in a given instance.
Furthermore, we do not believe it would be appropriate to establish a floor and ceiling for annual wage index changes which are above or below a given level. Any perceived volatility in the wage index would be based upon volatility in actual wages in that area, which is something outside of CMS's control. As stated above, under section 1888(e)(4)(G)(ii) of the Act and
After considering the comments received, for the reasons discussed above and in the FY 2015 SNF PPS proposed rule (79 FR 25775), we are finalizing our proposal to continue to use the updated hospital inpatient wage data, exclusive of the occupational mix adjustment, to develop the SNF PPS wage index. For FY 2015, the updated wage data are for hospital cost reporting periods beginning on or after
Once calculated, we apply the wage index adjustment to the labor-related portion of the federal rate, which is 69.180 percent of the total rate. This percentage reflects the labor-related relative importance for FY 2015, using the FY 2010-based SNF market basket. Each year, we calculate a revised labor-related share, based on the relative importance of labor-related cost categories (that is, those cost categories that are sensitive to local area wage costs) in the input price index. As discussed in section IV.B.2 of this final rule, for the FY 2014 SNF PPS update, we revised the labor-related share to reflect the relative importance of the revised FY 2010-based SNF market basket cost weights for the following cost categories: Wages and salaries; employee benefits; the labor-related portion of nonmedical professional fees; administrative and facilities support services; all other: Labor-related services (previously referred to in the FY 2004-based SNF market basket as labor-intensive); and a proportion of capital-related expenses.
We calculate the labor-related relative importance from the SNF market basket, and it approximates the labor-related portion of the total costs after taking into account historical and projected price changes between the base year and FY 2015. The price proxies that move the different cost categories in the market basket do not necessarily change at the same rate, and the relative importance captures these changes. Accordingly, the relative importance figure more closely reflects the cost share weights for FY 2015 than the base year weights from the SNF market basket.
We calculate the labor-related relative importance for FY 2015 in four steps. First, we compute the FY 2015 price index level for the total market basket and each cost category of the market basket. Second, we calculate a ratio for each cost category by dividing the FY 2015 price index level for that cost category by the total market basket price index level. Third, we determine the FY 2015 relative importance for each cost category by multiplying this ratio by the base year (FY 2010) weight. Finally, we add the FY 2015 relative importance for each of the labor-related cost categories (wages and salaries, employee benefits, the labor-related portion of non-medical professional fees, administrative and facilities support services, all other: Labor-related services, and a portion of capital-related expenses) to produce the FY 2015 labor-related relative importance. Tables 6 and 7 show the RUG-IV case-mix adjusted federal rates by labor-related and non-labor-related components. As discussed previously, the new OMB delineations will be used to identify a facility's urban or rural status for the purpose of determining which set of rate tables will apply to them beginning on
Table 6--RUG-IV Case-Mix Adjusted Federal Rates for Urban SNFs by Labor and Non-Labor Component RUG-IV category Total Labor Non-labor rate portion portion RUX 776.81$537.40 $239.41 RUL 759.88 525.68 234.20 RVX 691.42 478.32 213.10 RVL 620.32 429.14 191.18 RHX 626.43 433.36 193.07 RHL 558.72 386.52 172.20 RMX 574.64 397.54 177.10 RML 527.24 364.74 162.50 RLX 504.66 349.12 155.54 RUC 588.91 407.41181.50 RUB 588.91 407.41 181.50 RUA 492.42 340.66 151.76 RVC 505.21 349.50 155.71 RVB 437.50 302.66 134.84 RVA 435.81 301.49 134.32 RHC 440.23 304.55 135.68 RHB 396.21 274.10 122.11 RHA 348.81 241.31 107.50 RMC 386.74 267.55119.19 RMB 363.04 251.15 111.89 RMA 298.72 206.65 92.07 RLB 376.01 260.12 115.89 RLA 242.28 167.61 74.67 ES3 709.20 490.62 218.58 ES2 555.16 384.06 171.10 ES1 495.91 343.07 152.84 HE2 478.98 331.36 147.62 HE1 397.73 275.15 122.58 HD2 448.51 310.28 138.23 HD1 374.03 258.75 115.28 HC2 423.12 292.71 130.41 HC1 353.71 244.70 109.01 HB2 418.04 289.20 128.84 HB1 350.33 242.36 107.97 LE2 434.97 300.91 134.06 LE1 363.87 251.73 112.14 LD2 418.04 289.20 128.84 LD1 350.33 242.36 107.97 LC2 367.26 254.07 113.19 LC1 309.70 214.25 95.45 LB2 348.64 241.19 107.45 LB1 296.16 204.88 91.28 CE2 387.57 268.12 119.45 CE1 357.10 247.04 110.06 CD2 367.26 254.07 113.19 CD1 336.79 232.99 103.80 CC2 321.55 222.45 99.10 CC1 297.85 206.05 91.80 CB2 297.85 206.05 91.80 CB1 275.85 190.83 85.02 CA2 252.15 174.44 77.71 CA1 235.22 162.73 72.49 BB2 267.38 184.97 82.41 BB1 255.53 176.78 78.75 BA2 221.68 153.36 68.32 BA1 211.52 146.33 65.19 PE2 357.10 247.04 110.06 PE1 340.17 235.33 104.84 PD2 336.79 232.99 103.80 PD1 319.86 221.28 98.58 PC2 289.39 200.20 89.19 PC1 275.85 190.83 85.02 PB2 245.38 169.75 75.63 PB1 235.22 162.73 72.49 PA2 203.06 140.48 62.58 PA1 194.59 134.62 59.97
GOES
Table 7--RUG-IV Case-Mix Adjusted Federal Rates for Rural SNFs by Labor and Non-Labor Component RUG-IV category Total Labor Non-labor rate portion portion RUX 794.71$549.78 $244.93 RUL 778.54 538.59 239.95 RVX 698.27 483.06 215.21 RVL 630.35 436.08 194.27 RHX 625.35 432.62 192.73 RHL 560.66 387.86 172.80 RMX 568.30 393.15 175.15 RML 523.02 361.83 161.19 RLX 494.65 342.20 152.45 RUC 615.20 425.60189.60 RUB 615.20 425.60 189.60 RUA 523.02 361.83 161.19 RVC 520.38 360.00 160.38 RVB 455.69 315.25 140.44 RVA 454.07 314.13 139.94 RHC 447.45 309.55 137.90 RHB 405.41 280.46 124.95 RHA 360.13 249.14 110.99 RMC 388.79 268.96119.83 RMB 366.15 253.30 112.85 RMA 304.69 210.78 93.91 RLB 371.74 257.17 114.57 RLA 243.98 168.79 75.19 ES3 684.89 473.81 211.08 ES2 537.72 371.99 165.73 ES1 481.12 332.84 148.28 HE2 464.95 321.65 143.30 HE1 387.32 267.95 119.37 HD2 435.84 301.51 134.33 HD1 364.68 252.29 112.39 HC2 411.58 284.73 126.85 HC1 345.28 238.86 106.42 HB2 406.73 281.38 125.35 HB1 342.04 236.62 105.42 LE2 422.90 292.56 130.34 LE1 354.98 245.58 109.40 LD2 406.73 281.38 125.35 LD1 342.04 236.62 105.42 LC2 358.21 247.81 110.40 LC1 303.23 209.77 93.46 LB2 340.42 235.50 104.92 LB1 290.29 200.82 89.47 CE2 377.62 261.24 116.38 CE1 348.51 241.10 107.41 CD2 358.21 247.81 110.40 CD1 329.10 227.67 101.43 CC2 314.55 217.61 96.94 CC1 291.91 201.94 89.97 CB2 291.91 201.94 89.97 CB1 270.88 187.39 83.49 CA2 248.24 171.73 76.51 CA1 232.07 160.55 71.52 BB2 262.80 181.81 80.99 BB1 251.48 173.97 77.51 BA2 219.13 151.59 67.54 BA1 209.43 144.88 64.55 PE2 348.51 241.10 107.41 PE1 332.34 229.91 102.43 PD2 329.10 227.67 101.43 PD1 312.93 216.48 96.45 PC2 283.82 196.35 87.47 PC1 270.88 187.39 83.49 PB2 241.77 167.26 74.51 PB1 232.07 160.55 71.52 PA2 201.34 139.29 62.05 PA1 193.26 133.70 59.56
Section 1888(e)(4)(G)(ii) of the Act also requires that we apply this wage index in a manner that does not result in aggregate payments under the SNF PPS that are greater or less than what would otherwise be made if the wage adjustment had not been made. For FY 2015 (federal rates effective
In the SNF PPS final rule for FY 2006 (70 FR 45026,
In adopting the
On
While the revisions OMB published on
As discussed in the SNF PPS proposed rule for FY 2014 (78 FR 26448), the changes made by the bulletin and their ramifications required extensive review by CMS before using them for the SNF PPS wage index. Having completed our assessment, in the FY 2015 SNF PPS proposed rule (79 FR 25779 through 25786), we proposed changes to the SNF PPS wage index based on the newest OMB delineations, as described in OMB Bulletin No. 13-01, beginning in FY 2015, including a proposed 1-year transition with a blended wage index for FY 2015. These changes, and associated comments, are discussed further in section IV.D.1. of this final rule. The wage index applicable to FY 2015 is set forth in Table A available on the CMS Web site at http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/WageIndex.html. Table A provides a crosswalk between the FY 2015 wage index for a provider using the current OMB delineations in effect in FY 2014 and the FY 2015 wage index using the revised OMB delineations, as well as the transition wage index values that will be in effect in FY 2015.
5. Adjusted Rate Computation Example
Using the hypothetical SNF XYZ described below, Table 8 shows the adjustments made to the federal per diem rates to compute the provider's actual per diem PPS payment. We derive the Labor and Non-labor columns from Table 6. The wage index used in this example is based on the transition wage index, which may be found in Table A as referenced above. As illustrated in Table 8, SNF XYZ's total PPS payment would equal
Table 8--Adjusted Rate Computation Example SNF XYZ: Located inCedar Rapids, IA (Urban CBSA 16300) Wage Index: 0.8850 [See Transition Wage Index in Table A] *1 RUG-IV Labor Wage Ad- Non- Ad- Percent Medi- Payment group index justed labor justed adjust- care labor rate ment days RVX$ 0.885 $ $ $$ 14 $8,909.74 478.32 423.31 213.10 636.41 636.41 ES2 384.06 0.885 339.89 171.10 510.99 510.99 30 15,329.70 RHA 241.31 0.885 213.56 107.50 321.06 321.06 16 5,136.96 CC2 * 222.45 0.885 196.87 99.10 295.97 674.81 10 6,748.10 BA2 153.36 0.885 135.72 68.32 204.04 204.04 30 6,121.20 *1 Available on the CMS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/WageIndex.html.
C. Additional Aspects of the SNF PPS
1. SNF Level of Care--Administrative Presumption
The establishment of the SNF PPS did not change
In accordance with section 1888(e)(
A beneficiary assigned to any of the lower 14 RUG-IV groups is not automatically classified as either meeting or not meeting the definition, but instead receives an individual level of care determination using the existing administrative criteria. This presumption recognizes the strong likelihood that beneficiaries assigned to one of the upper 52 RUG-IV groups during the immediate post-hospital period require a covered level of care, which would be less likely for those beneficiaries assigned to one of the lower 14 RUG-IV groups.
In the
* Rehabilitation plus Extensive Services;
* Ultra High Rehabilitation;
* Very High Rehabilitation;
* High Rehabilitation;
* Medium Rehabilitation;
* Low Rehabilitation;
* Extensive Services;
*
* Special Care Low; and,
*
However, we note that this administrative presumption policy does not supersede the SNF's responsibility to ensure that its decisions relating to level of care are appropriate and timely, including a review to confirm that the services prompting the beneficiary's assignment to one of the upper 52 RUG-IV groups (which, in turn, serves to trigger the administrative presumption) are themselves medically necessary. As we explained in the FY 2000 SNF PPS final rule (64 FR 41667), the administrative presumption:
* . . is itself rebuttable in those individual cases in which the services actually received by the resident do not meet the basic statutory criterion of being reasonable and necessary to diagnose or treat a beneficiary's condition (according to section 1862(a)(1) of the Act). Accordingly, the presumption would not apply, for example, in those situations in which a resident's assignment to one of the upper . . . groups is itself based on the receipt of services that are subsequently determined to be not reasonable and necessary.
Moreover, we want to stress the importance of careful monitoring for changes in each patient's condition to determine the continuing need for Part A SNF benefits after the assessment reference date of the 5-day assessment.
2. Consolidated Billing
Sections 1842(b)(6)(E) and 1862(a)(18) of the Act (as added by section 4432(b) of the BBA) require a SNF to submit consolidated
A detailed discussion of the legislative history of the consolidated billing provision is available on the SNF PPS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Legislative_History_07302013.pdf. In particular, section 103 of the
As explained in the FY 2001 proposed rule (65 FR 19232), the amendments enacted in section 103 of the BBRA not only identified for exclusion from this provision a number of particular service codes within four specified categories (that is, chemotherapy items, chemotherapy administration services, radioisotope services, and customized prosthetic devices), but also gave the Secretary ". . . the authority to designate additional, individual services for exclusion within each of the specified service categories." In the proposed rule for FY 2001, we also noted that the
As we further explained in the final rule for FY 2001 (65 FR 46790), and as our longstanding policy, any additional service codes that we might designate for exclusion under our discretionary authority must meet the same statutory criteria used in identifying the original codes excluded from consolidated billing under section 103(a) of the BBRA: They must fall within one of the four service categories specified in the BBRA; and they also must meet the same standards of high cost and low probability in the SNF setting, as discussed in the
Comment: One commenter recommended four particular chemotherapy drugs for exclusion. As described by Healthcare Common Procedure Coding System (HCPCS) code J8562, the first drug (fludarabine phosphate, 10 mg) is administered orally, but this same drug is already excluded under code J9185 when administered in a 50 mg dosage via intravenous injection. The commenter incorrectly characterized the second recommended drug, Revlimid (lenalidomide), as being assigned to code J3590 (whose descriptor is actually "unclassified biologic"); in fact, that drug, along with the commenter's third recommended drug, Zytiga (Abiraterone acetate), is not assigned a specific code of its own, but instead comes under the heading of one of the broader, "not otherwise specified" (NOS) codes, J8999 ("Prescription drug, oral, chemotherapeutic, NOS"). The fourth chemotherapy drug that the commenter recommended for exclusion was code J9219 (Leuprolide acetate implant, 65 mg).
Response: Regarding the first drug that the commenter cited (code J8562), the only oral fludarabine product is Oforta(R), which was withdrawn from the market in
Regarding the comment involving two chemotherapy drugs that have not been assigned their own specific HCPCS codes, we note that the assignment of such a code has been an essential element of identifying certain chemotherapy drugs for exclusion ever since the BBRA first created the statutory exclusion list in 1999, as reflected in the drafting of the statutory provision itself as well as in our periodic solicitation of "codes" that might meet the criteria for exclusion. When the
Regarding code J9219 (Leuprolide acetate implant, 65 mg), we have noted previously in the FY 2008 SNF PPS final rule (72 FR 43431,
* . . is a hormonal agent which is clinically analogous to other existing codes that have not been designated for exclusion; moreover, as this drug is used in treating the commonly-occurring condition of prostate cancer, we believe that it is unlikely to meet the criterion of "low probability" specified in the BBRA.
Comment: One commenter reiterated recommendations that commenters had repeatedly urged us to adopt in previous years, by expanding the existing chemotherapy exclusion to encompass related drugs that are commonly administered in conjunction with chemotherapy to ameliorate the side effects of the chemotherapy drugs, and by excluding certain additional categories of services beyond those specified in the BBRA, such as the antibiotic drug, Vancomycin. Another commenter cited previously-expressed objections from numerous prior public comment periods regarding the limited scope of the existing administrative exclusion for certain specified types of high-intensity outpatient services (which applies only when such services are furnished in the outpatient hospital setting and not when furnished in other, freestanding settings), and stated that this exclusion should focus on the nature of the excluded service itself rather than on the location in which the service is furnished.
Response: Regarding the exclusion of chemotherapy-related drugs, we have noted repeatedly in this and previous final rules--such as the FY 2014 SNF PPS final rule (78 FR 47958-59,
* . . as we initially noted in the FY 2009 SNF PPS final rule (73 FR 46436,
Moreover, we note that when the
Comment: One commenter reiterated the recurring objections to excluding certain high-intensity outpatient services only when furnished in the hospital setting, specifically in the context of radiation therapy. However, in addition to restating the same positions on this point that had already been advanced and addressed repeatedly in prior rules--most recently, in the FY 2014 SNF PPS final rule (78 FR 47957-58,
Response: We note that two of the specific codes (79300 and 79403) that the commenter recommended adding to the list of excluded radioisotope services already appear as such in Major Category III.C ("Radioisotopes and their Administration") of the online exclusion list, which is available in the 2014 Part A MAC Update at http://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2014-Part-A-MAC-Update.html. Beyond that, we agree that the statutory exclusion of radioisotope services at section 1888(e)(2)(A)(iii)(IV) of the Act is not confined to the fairly narrow range of 79000-series codes specified in the law itself (identifying systemic radioisotopes administered through infusion or oral ingestion), but rather, is intended to encompass all of the "high-cost, low probability" forms of radiation treatment that actually involve the use of radioisotope services (which can include brachytherapy as well). Accordingly, we will make appropriate revisions in Major Category III.C to reflect this, by adding the brachytherapy-related code 77014 (computed tomography guidance for placement of radiation therapy fields for brachytherapy), as well as the clinical brachytherapy code range of 77750 to 77799. However, we are not adding external beam radiation therapy to this category of the exclusion list (even when it involves the use of the radioisotope Cobalt 60) in view of the commenter's characterization of this particular radioisotope application in terms that would raise questions about whether it continues to be used as well as inherent questions about its safety and efficacy in this context. In our discussion of the statutory exclusion for chemotherapy services in the FY 2014 SNF PPS final rule, we noted that ". . . when an otherwise excluded chemotherapy drug is prescribed for a use that does not involve treating cancer, the drug would not qualify as an excluded `chemotherapy' drug in that instance" (78 FR 47958). Similarly, we note that to the extent any of the additional brachytherapy codes we now specify for exclusion as "radioisotope services" under section 1888(e)(2)(A)(iii)(IV) of the Act could serve to identify non-radioisotope, as well as radioisotope procedures, the radioisotope exclusion under Major Category III.C would apply only in those particular instances that actually involve the use of radioisotopes. (Of course, even when associated with a non-radioisotope procedure, a particular code that also appears in Major Category I.D ("Radiation Therapy") of the online exclusion list could still qualify for exclusion on that basis when furnished in the outpatient hospital setting.)
We are also not adopting the commenter's recommendation to exclude a number of supplemental but more generic clinical treatment and planning codes beyond those that specifically identify the actual performance of the radioisotope procedure itself. We decline to exclude such codes, not because these supplemental activities would never occur in connection with a radioisotope procedure (as this is indeed possible in certain instances), but rather, because they are unlikely in themselves to meet the "high-cost, low probability" threshold which determines those specific radioisotope services that qualify for exclusion under this provision. We believe that for treatments involving the use of radioisotope services, it is the actual performance of the radioisotope procedure itself (rather than any associated preparatory and planning activities) that would account for the preponderance of the cost, so that those separate, supplemental codes would be unlikely in themselves to meet the "high-cost" threshold for exclusion. Similarly, we do not believe that these supplemental codes would meet the "low probability" criterion, as they are associated not just with radioisotope procedures alone, but also more generally with various other, more commonly used forms of radiation treatment.
Moreover, we do not share the commenter's view that the "specified service category" at issue here is the Part B benefit category at section 1861(s)(4) of the Act, which provides for broader coverage of radiation treatment beyond just that involving the use of radioisotope services. We note that the statutory exclusion for "radioisotope services" at section 1888(e)(2)(A)(iii)(IV) of the Act stands in marked contrast, for example, to the ones for dialysis and erythropoietin (EPO) at section 1888(e)(2)(A)(ii) of the Act, which consist of--and, in fact, are defined by--explicit cross-references to the corresponding Part B benefit categories appearing in sections 1861(s)(2)(F) and 1861(s)(2)(O) of the Act, respectively. Conversely, the statutory exclusion at section 1888(e)(2)(A)(iii)(IV) of the Act does not contain such a cross-reference to the Part B benefit category at section 1861(s)(4) of the Act for general coverage of radiation treatments, and thus, applies specifically to "radioisotope services" alone.
3. Payment for SNF-Level Swing-Bed Services
Section 1883 of the Act permits certain small, rural hospitals to enter into a
Accordingly, all non-CAH swing-bed rural hospitals have now come under the SNF PPS. Therefore, all rates and wage indexes outlined in this final rule for the SNF PPS also apply to all non-CAH swing-bed rural hospitals. A complete discussion of assessment schedules, the MDS, and the transmission software (RAVEN-SB for Swing Beds) appears in the FY 2002 final rule (66 FR 39562) and in the FY 2010 final rule (74 FR 40288). As finalized in the FY 2010 SNF PPS final rule (74 FR 40356 through 40357), effective
D. Other Issues
1. Proposed Changes to the SNF PPS Wage Index
a. Background
Section 1888(e)(4)(G)(ii) of the Act requires that we adjust the federal rates to account for differences in area wage levels, using a wage index that the Secretary determines appropriate. Since the inception of the SNF PPS, we have used hospital inpatient wage data, exclusive of the occupational mix adjustment, in developing a wage index to be applied to SNFs. As noted previously in section IV.B.4. of this final rule, we will continue that practice for FY 2015. The wage index used for the SNF PPS is calculated using the Inpatient Prospective Payment System (IPPS) wage index data on the basis of the labor market area in which the acute care hospital is located, but without taking into account geographic reclassifications under section 1886(d)(8) and (d)(10) of the Act, and without applying the IPPS rural floor under section 4410 of the BBA, the IPPS imputed rural floor under 42 CFR 412.64(h), the frontier state floor under section 1886(d)(3)(E)(iii) of the Act, and the outmigration adjustment under section 1886(d)(13) (see the FY 2006 SNF PPS proposed rule (70 FR 29090 through 29095)). The applicable SNF wage index value is assigned to a SNF on the basis of the labor market area in which the SNF is geographically located. Under section 1888(e)(4)(G)(ii) of the Act, beginning with FY 2006, we delineate labor market areas based on the Core-Based Statistical Areas (CBSAs) established by the
While the revisions OMB published on
Comment: We received a few comments on the proposed implementation of the new OMB delineations for the SNF PPS wage index, primarily focused on how such changes would be implemented. Specifically, one commenter requested a 2-year phase-in (rather than our proposed 1-year transition) for the proposed wage index changes. Other commenters stated that CMS should utilize similar implementation policies for the SNF wage index changes as were proposed for hospital providers in the FY 2015 Inpatient Prospective Payment System (IPPS) proposed rule (79 FR 27978). More specifically, these commenters urged CMS to establish a three-year transition policy (similar to that proposed under IPPS) for urban SNFs that would become rural under the new OMB delineations.
Response: As noted in the FY 2015 SNF PPS proposed rule (79 FR 25785), we considered proposing a multi-year transition approach, whether it be 2, 3, or some other number of years, in order minimize the impact of the proposed wage index changes in a given year. However, we also believe this must be balanced against the need to ensure the most accurate payments possible based on the most current geographic delineations, which supports the use of a shorter transition to the revised OMB delineations. As discussed in the FY 2015 SNF PPS proposed rule (79 FR 25785), we believe that using the most current OMB delineations would increase the integrity of the SNF PPS wage index by creating a more accurate representation of geographic variation in wage levels. As such, we believe that utilizing a 1-year (rather than a multiple-year) transition with a blended wage index in FY 2015 would strike the best balance.
It should also be noted that the implementation of the revised OMB delineations, which we are finalizing in this rule, sets SNF payments at a level that more accurately reflects the costs of labor in a SNF's geographic area. Accordingly, under this policy, SNFs will experience a decrease from their current wage index value only to the extent that their current wage index value actually exceeds what the latest area wage data warrants using the revised OMB delineations, and they will experience an increase from their current wage index value to the extent that their current wage index value is less than what the latest area wage data warrants using the revised OMB delineations. We believe that pursuing a longer transition period would advantage the former group by delaying implementation of the full decrease in their wage index values under the new OMB delineations, at the further expense of the latter group which would experience an extended delay in implementation of the full increase in their wage index values. We believe that utilizing a 1-year (rather than a multiple-year) transition with a blended wage index in FY 2015 strikes an appropriate balance between the interests of these two groups of providers.
Commenters also suggested that CMS consider a 3-year transition methodology similar to that proposed in the FY 2015 IPPS proposed rule. In the FY 2015 IPPS proposed rule, CMS proposed a 3-year transition for those hospitals that are currently in urban areas that would become rural under the new OMB delineations, under which such hospitals would receive the urban wage index of the
To further address commenters' general suggestion that we utilize similar implementation policies as were proposed for hospital providers in the FY 2015 IPPS proposed rule, we also considered whether it would appropriate to apply a variation of the 3-year transition discussed above, pursuant to which SNFs that would experience a decrease in their wage index under the new OMB delineations would receive the wage index of the
While we understand the concern raised by these commenters regarding the potential impact on the subset of SNFs that would experience a decrease in their wage index, we believe this must be weighed against the interests of and impact on all SNFs. As discussed above, and in the SNF PPS proposed rule (79 FR 25785), we believe that our proposed 1-year transition policy with a 50/50 blended wage index for all SNFs appropriately mitigates the negative payment impacts on SNFs that will experience a wage index decrease due to implementation of the new OMB delineations, while having the least impact on the rest of the facilities.
Accordingly, for the reasons specified in this final rule and in the FY 2015 SNF PPS proposed rule (79 FR 25779 through 25786), we are finalizing, without modification, our proposal to implement the new OMB delineations as described in the
The wage index applicable to FY 2015 is set forth in Table A available on the CMS Web site at http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/WageIndex.html. Table A provides a crosswalk between the FY 2015 wage index for a provider using the current OMB delineations in effect in FY 2014 and the FY 2015 wage index using the revised OMB delineations, as well as the transition wage index values that will be in effect in FY 2015.
a. Labor-Related Share
Each year, we calculate a revised labor-related share based on the relative importance of labor-related cost categories in the SNF market basket as discussed in section IV.B.4 of this final rule. Table 12 summarizes the updated labor-related share for FY 2015, compared to the labor-related share that was used for the FY 2014 SNF PPS final rule. GOES
Table 12--Labor-Related Relative Importance, FY 2014 and FY 2015 Relative Relative importance, importance, labor-related, labor-related, FY 2014 FY 2015 13:2 forecast *1 14:2 forecast *2 Wages and salaries 49.118 48.816 Employee benefits 11.423 11.365 Nonmedical Professional 3.446 3.450 fees: Labor-related Administrative and 0.499 0.502 facilities support services All Other: Labor-related 2.287 2.276 services Capital-related (.391) 2.772 2.771 Total 69.545 69.180. *1 Published in theFederal Register ; based on second quarter 2013 IGI forecast. *2 Based on second quarter 2014 IGI forecast, with historical data through first quarter 2014.
2.
As discussed in the FY 2014 SNF PPS proposed rule (78 FR 26466,
In the FY 2015 SNF PPS proposed rule (79 FR 25786), we provided an update on the current state of this project and invited public comments on this project. The comments we received on this topic, with their responses, appear below.
Comment: All of the comments we received on this work supported CMS's research effort in developing a new methodology for paying for therapy services received in the SNF. Most commenters urged CMS to expedite the research necessary to develop a new therapy payment model, with one commenter expressing disappointment that CMS has not implemented a model to date. A few commenters stated that CMS should seek input from stakeholders on how best to revise the current therapy payment model.
Response: We appreciate the broad support for this research initiative and understand the importance of completing this work in both a timely and efficient manner. We also recognize the importance of seeking input from stakeholders on how best to revise the current therapy payment model, which is why one of our central focuses in leading this research effort has been to solicit stakeholder feedback through listening sessions and through the creation of a SNF therapy research email box at [email protected]. Stakeholders can send input on a revised therapy payment model to this email box at any time, and every email is read and considered by both CMS staff and contractors. We also plan to solicit feedback through more formal avenues such as a technical expert panel in the near future.
Currently, we are closely examining all of the models that have been suggested for improving SNF therapy payment, including but not limited to models developed by MedPAC and the
In terms of the timeframe for completing this work and implementing a new payment model, we believe it would be premature at this time to speculate on when a new model will be ready to be implemented. As many of the comments on this issue indicate, it is very important to ensure that any change to the current therapy payment model addresses any concerns with the existing model, provides the proper incentives to treat patients in the most appropriate and efficient way, and provides sufficient time for providers to understand and prepare for implementation of such a model.
Comments on this topic may still be provided outside the rulemaking process, and these comments should be sent via email to [email protected]. Information regarding this project can be found on the project Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html.
3. Proposed Revisions to Policies Related to the Change of Therapy (COT) Other Medicare Required Assessment (OMRA)
In the FY 2015 SNF PPS proposed rule (79 FR 25786 through 25788), we discussed proposed changes to the existing COT OMRA policy which would permit providers to complete a COT OMRA for a resident who is not currently classified into a RUG-IV therapy group or receiving a level of therapy sufficient for classification into a RUG-IV therapy group, but only in those rare cases where the resident had qualified for a RUG-IV therapy group on a prior assessment during the resident's current Medicare Part A stay, and had no discontinuation of therapy services between Day 1 of the COT observation period for the COT OMRA that classified the resident into his/her current non-therapy RUG-IV group and the ARD of the COT OMRA that reclassified the patient into a RUG-IV therapy group. The comments we received on this proposal, along with our responses, appear below.
Comment: All of the comments we received on this topic supported the proposed revision to the existing COT OMRA policies. One commenter stated that this proposal is not necessary, stating that the current COT OMRA policy already allows for providers to complete a COT OMRA in the circumstances proposed in the FY 2015 SNF PPS proposed rule.
Response: We appreciate the broad support we received on this proposal. With regard to the comment that this proposal is not necessary, we would note that the FY 2012 SNF PPS final rule (78 FR 48525 through 48526) and section 2.9 of the MDS RAI manual (available at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html) clearly state that the COT OMRA is to be used in those cases where the patient is classified into a RUG-IV therapy category, or where the patient is receiving a level of therapy sufficient for classification into a therapy RUG (but is classified into a nursing RUG because of index maximization). That providers may have misinterpreted the rules and are currently using the COT OMRA in a manner that is inconsistent with these guidelines does not affect how the policy was finalized and implemented. We would encourage providers to examine their current COT OMRA completion protocols to ensure they are aligned with existing COT OMRA guidelines, as provided in the aforementioned references, and immediately address any assessments that were completed inappropriately.
Comment: Several commenters highlighted an issue in the second example that begins on page 25787 of the FY 2015 SNF PPS proposed rule. Specifically, these commenters pointed out that because the resident is no longer in a RUG-IV therapy group, an End of Therapy (EOT) OMRA would not be completed on this resident when the discontinuation of therapy occurs as this would violate the rules associated with the EOT OMRA, which require that the resident be in a RUG-IV therapy group for this assessment to be completed. These commenters requested that an additional example be added here to clarify this second example and the scope of this proposed revision. Finally, a few commenters requested that CMS provide as much detail as possible in this final rule regarding how this policy will be implemented and how this revision to the COT OMRA policy may affect other OMRAs.
Response: We agree with the commenters that the reference to completing an EOT OMRA in the second example on page 25787 of the FY 2015 SNF PPS proposed rule is incorrect. To address this issue, below we provide a new example that is intended to clarify the scope of this proposed revision to the COT OMRA policy.
Assume Mr. A is classified into the RUG group RUA on his 30-day assessment with an ARD set for Day 30 of his stay. On Day 37, the facility checks the amount of therapy that was provided to Mr. A and finds that while Mr. A did receive the requisite number of therapy minutes to qualify for this RUG category, he only received therapy on 4 distinct calendar days, which would make it impossible for him to qualify for an Ultra-High Rehabilitation RUG group. Moreover, due to the lack of 5 distinct calendar days of therapy and the lack of any restorative nursing services, Mr. A does not qualify for any therapy RUG group. As a result, the facility must complete a COT OMRA for Mr. A, on which he may only classify for a non-therapy RUG group. However, as opposed to the first example found on page 25787 of the FY 2015 SNF PPS proposed rule, where the resident's therapy continued during the week following the COT OMRA, let us assume the facility decides to discontinue his therapy services, with Day 39 representing the last day that Mr. A is provided therapy. The facility subsequently decides to provide Mr. A with therapy services due to observing Mr. A's deteriorating condition, with the first day of new therapy services being Day 48. On Day 54 (7 days following the day therapy began on Day 48, including Day 48) the facility reviews the therapy services provided to Mr. A during the prior week and finds that Mr. A would qualify for the RUG group RUA.
As intended in the second example in the FY 2015 SNF PPS proposed rule (79 FR 25787), this example represents a scenario where, under both the current and proposed COT OMRA policies, a COT OMRA may not be completed. This is because a discontinuation of therapy services occurred. To clarify our example and the scope of the proposed revision to the COT OMRA policy, we note that "discontinuation of therapy services" is defined in a manner consistent with how this phrase is described in the FY 2010 SNF PPS final rule (76 FR 40346 through 40349), the FY 2012 SNF PPS final rule (78 FR 48517 through 48522), and Chapter 2, Section 2.9, of the MDS RAI manual. Consistent with what constitutes a discontinuation of therapy more globally within the SNF PPS, a "discontinuation of therapy" here refers to the planned or unplanned discontinuation of all rehabilitation therapies for 3 or more consecutive days. This was the actual intent of the erroneous reference to the EOT OMRA in the FY 2015 SNF PPS proposed rule, as noted by these commenters. In essence, the same criteria used to determine the need for an EOT OMRA (which is that the resident does not receive therapy services for 3 consecutive calendar days) will be used under our revised COT OMRA policy to determine whether there has been a discontinuation of therapy services and thus whether a COT OMRA may be completed for a given resident. In the above example, since the resident did not receive therapy services for 8 days, this would represent a discontinuation of therapy services as defined above and the COT OMRA that was planned with an ARD of Day 54 would not be permissible, both under our current policy and under our proposed revised COT OMRA policy.
With regard to comments on how this revision would affect other OMRAs, the answer is that it does not have any impact on the other OMRAs within the SNF PPS. The rules and policies associated with all other assessment types remain the same. We also plan to provide additional details on the operation of this revised policy in a forthcoming MDS RAI manual revision, which would be effective
Accordingly, for the reasons specified in this final rule and in the FY 2015 SNF PPS proposed rule (79 FR 25786 through 25788), we are finalizing our proposal to permit providers, in certain circumstances (discussed below), to complete a COT OMRA for a resident who is not currently classified into a RUG-IV therapy group, or receiving a level of therapy sufficient for classification into a RUG-IV therapy group. As discussed above, this would be allowed only in those rare cases where the resident had qualified for a RUG-IV therapy group on a prior assessment during the resident's current Medicare Part A stay, and had no discontinuation of therapy services between Day 1 of the COT observation period for the COT OMRA that classified the resident into his/her current non-therapy RUG-IV group and the ARD of the COT OMRA that reclassified the patient into a RUG-IV therapy group. This change in policy will be effective
4. Civil Money Penalties (section 6111 of the Affordable Care Act)
In the FY 2015 SNF PPS proposed rule (79 FR 25788 through 25789), we discussed clarifications related to statutory requirements as specified in section 6111 of the Affordable Care Act regarding the approval and use of civil money penalties imposed by CMS. Further, we proposed changes to the CMS enforcement regulations at
Comment: A few commenters requested that we specify the requirements and CMS's expectations for soliciting civil money penalty funds and tracking approved civil money penalty projects. One commenter suggested that we establish a formula to determine how much is appropriate for a state to keep in reserve each year. Several commenters suggested that CMS should specify how information should be made public by the state, including the availability of grants, approved projects funded to date and the outcomes of previously funded projects. One commenter states that the proposed rule lacks clarity regarding what constitutes an "acceptable" state plan and how CMS would make such a determination.
Response: Specific operational details regarding our expectations for the state are not appropriate for inclusion in regulation. We plan to issue subsequent guidance regarding these operational details and publish this guidance in the State Operations manual.
Comment: One commenter asked if states will be required to share their acceptable plan for the effective use of civil money penalty funds with CMS. One commenter recommends formal CMS approval of all plans and public disclosure once the plan is approved. One commenter asked if CMS will require the acceptable plan be posted on some Web site.
Response: We will require states to submit their plans to their respective CMS Regional Offices for formal approval. We have revised
Comment: One commenter asked if CMS has any plans to publicly report the amount of civil money penalty funds collected and returned to the states. Another commenter stated that CMS should publish a link to information on state's civil money penalty account balances on
Response: We will make key information publicly available regarding approved projects, CMP grant awards, and CMP funds disbursed to states. We will explore appropriate methods to present information in a manner that will be accessible and meaningful to the public. Currently, all projects that a state is recommending for approval are submitted to the
In response to these comments, we will consider issuing guidance to states regarding making the information about their state plans for civil money penalties as well as approved civil money penalty projects publicly available, as required in this final rule, by posting on a state Web site and making sure that this information is updated on an annual basis. As to the length of time of the posting, we would anticipate that states would post a new report about the use of penalty funds on an annual basis that would include currently funded projects as well as information, or links to the information, for projects funded after this regulation even if the projects have ended.
Comment: One commenter asked us to clarify what the terms "results of projects" and "other key information" would involve when we proposed that states "make information about the use of civil money penalty funds publicly available, including about the dollar amount awarded for approved projects, the grantee or contract recipients, the results of projects, and other key information."
Response: We expect that states track the results of approved projects. Projects funded with civil money penalty monies should have clear goals and methodologies to achieve those goals. States will be required to make information available about the outcome or results of completed projects. These results should include the grant recipient, amount and duration of the grant, purpose and goals of the project, results of the project (for example, whether or not the project was successful), lessons learned, and similar key information, such as whether improvements have been institutionalized as a result of the project. Most importantly, we hope that the publicly-shared information would help others to gain insight into the methodologies to achieve important quality of care or quality of life goals, even if the project was not successful in achieving such goals within the time period of the civil money penalty grant.
Comment: One state asked that if there is a year when a state does not receive civil money penalty proposals that meet the CMS criteria, what would be the required next steps for a state to take.
Response: If there is a year that a state has actively solicited for proposals and still receives no proposals that meet the CMS criteria for approval, then we would work with the state to explore opportunities to fund worthwhile projects that would benefit nursing home residents. We would do this by looking at the state's solicitation process, using successful projects that have been funded by other states as a model, and offering any guidance necessary to ensure that civil money penalty funds are being utilized for their intended purpose.
Comment: We received several comments regarding the language at
Response: We agree that civil money penalty funds should not be used to pay for activities, functions, or products that nursing homes are required to provide. At the same time, we believe there is a tremendous need for knowledge and sharing of important ways to provide care and achieve results that may transcend the basic requirements in our regulations. Because there is a challenge to providing technical assistance while avoiding any supplanting of nursing home responsibilities, we require that proposed projects be approved by CMS and publicly reported. We expect, over time, that we will learn more about the projects that achieve the appropriate balance between providing effective technical assistance that advances the quality of care and quality of life for residents without supplanting what nursing homes are already required to do. At the present time we have already identified in CMS published guidance a variety of uses that are prohibited, and believe that the identified prohibitions are sufficient for now. With regard to QAPI in particular, section 1128I(c) of the Act directs CMS to provide technical assistance to facilities on the development of best practices in order to meet CMS' established QAPI standards. We expect most of the technical assistance will be done by the Quality Improvement Organizations (QIOs), but do not rule out the use of CMP funds for very targeted purposes that the QIOs are not able to accomplish, especially for nursing homes that have a high reliance on
Comment: While the proposed language at
Response: At
Comment: One commenter stated that they did not support the use of civil money penalty funds for the joint training of facility staff and surveyors and suggested that this use be a low level priority, be limited, and include other interested parties, such as consumers, ombudsman and advocates. This commenter also urged CMS to restore the language at the end of proposed
Response: We believe that there are benefits for joint training between State survey agencies and nursing home providers to improve understanding of federal requirements and to communicate specific policies and procedures. In fact, we have sponsored such joint trainings on a national basis dating back to the implementation of the nursing home reform provisions of Omnibus Budget Reconciliation Act of 1987 (OBRA '87) to train both states and providers in the new health and safety requirements and enforcement rules. To provide optimum flexibility of such training, we do not propose to limit or to require other stakeholders in joint trainings nor do we propose to limit the facilities that may utilize civil money penalty funds for joint training to only those facilities that have been cited by CMS for deficiencies under the applicable requirements. However, we do agree that this is a lower-priority use of CMP funds and ought to be limited to special situations. We will further address this issue in CMS guidance.
Comment: One commenter suggested that CMS should not limit itself to only withholding future civil money penalty disbursements in cases where states routinely failed to comply with the acceptable use of civil money penalty funds. They suggested referral to the
Response: Specific operational details regarding the withholding of future civil money penalty disbursements to a state are not appropriate for inclusion in regulation. We plan to issue subsequent guidance regarding these operational details and publish this guidance in the State Operations Manual. While we appreciate the suggestions offered for further enforcement action when states are not complying with the acceptable uses of civil money penalty funds as specified in
Comment: Several commenters suggested that CMS develop a standardized application for use of civil money penalty funds. This application should clearly articulate how the proposed use is not duplicative of statutorily mandated services, including those related to quality of care or quality of life, and how residents, families, long term care ombudsman and consumer representatives were included in the development of the proposed use and how they will be engaged in the project activities.
Response: We agree, and will develop a standardized application that states may make available to any entities seeking to submit proposals for projects to be funded with civil money penalties. We expect that such a template should be completed by early CY 2015.
Comment: One commenter suggested that CMS allow states more autonomy to award civil money penalty funds to applicants consistent with CMS-prescribed guidelines. They further noted that because states vary in their specific needs, they are more knowledgeable about how to best meet their needs in order to best serve the beneficiaries and residents/patients of nursing centers within the state.
Response: We will consider ways in which states may gain more autonomy over time, as we learn more about projects that are successful, are able to fully implement the additional processes in this regulation, and work with stakeholders. We recognize the critical role that states play and wish to bolster state ability to use civil money penalty funds effectively. Under the arrangements already in place, proposals for projects utilizing civil money penalty funds are submitted directly to the state survey agency. The state conducts the initial review of all proposals and forwards those that meet CMS criteria and that they are recommending for final approval to the CMS regional office. We believe the regulations we are finalizing here will make the entire state civil money penalty program more coherent, more transparent, and more effective.
Comment: One commenter recommends that states be allowed to align their civil money penalty grant process with their fiscal year in order to coordinate existing state grant process timeframes.
Response: We have no objections to states aligning their civil money penalty grant process with their fiscal year.
5. Observations on Therapy Utilization Trends
In the FY 2015 SNF PPS proposed rule, we discussed recent observed trends related to therapy service provision under the SNF Part A benefit, specifically with regard to overall therapy case-mix distribution trending toward more residents classifying into the Ultra-High Rehabilitation groups, and therapy being reported on the MDS in amounts that are just enough to surpass the relevant therapy minute threshold for a given therapy RUG category. We also posted a memo on the SNF PPS Web site (available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Spotlight.html) which discussed these trends in greater depth. Finally, we invited comment on the data presented in the proposed rule (and associated memo) and the discussion of observed trends. The comments we received on this topic, as well as our responses, appear below.
Comment: We received a number of comments on the discussion of observed therapy trends. All of the commenters supported CMS in monitoring these trends, with a few offering their own data analytics surrounding the same issues raised in the memo referenced above. A few commenters highlighted the lack of current medical evidence related to how much therapy a given resident should receive. One commenter recommended that CMS ensure that access to specialty populations be accounted for in our monitoring efforts. Another commenter highlighted that the trends memo provides evidence of concerns and issues of which they have become aware related to therapy minute demands on practitioners, shortened evaluation times, and pressure to reduce services inappropriately. This commenter also noted that the minimum minutes for a RUG level are often perceived as maximum minutes and that some providers may implement internal rules that prohibit clinicians, against their own professional judgment from providing therapy above the RUG levels.
Response: We appreciate the support for our continued monitoring efforts. As always, we appreciate any assistance that stakeholders may wish to provide in terms of understanding existing trends and data.
With regard to the comments which highlight the lack of existing medical evidence for how much therapy a given resident should receive, we would note that the trends memo was not intended to address such an issue. The memo was merely intended to highlight a trend indicating that, the current state of medical evidence on this point notwithstanding, the number of therapy minutes provided to SNF residents within certain therapy RUG categories is, in fact, clustered around the minimum thresholds for a given therapy RUG category. However, given the comments highlighting the lack of medical evidence related to the appropriate amount of therapy in a given situation, it is all the more concerning that practice patterns would appear to be as homogenized as the data would suggest.
With regard to the comment on specialty populations, we agree with the commenter that access must be preserved for all categories of SNF residents, particularly those with complex medical and nursing needs. As appropriate, we will examine our current monitoring efforts to identify any revisions which may be necessary to account appropriately for these populations.
With regard to the comment which highlighted potential explanatory factors for the observed trends, such as internal pressure within SNFs that would override clinical judgment, we find these potential explanatory factors troubling and entirely inconsistent with the intended use of the SNF benefit. Specifically, the minimum therapy minute thresholds for each therapy RUG category are certainly not intended as ceilings or targets for therapy provision. As discussed in Chapter 8, Section 30 of the Medicare Benefit Policy Manual (Pub. 100-02), to be covered, the services provided to a SNF resident must be "reasonable and necessary for the treatment of a patient's illness or injury, that is, are consistent with the nature and severity of the individual's illness or injury, the individual's particular medical needs, and accepted standards of medical practice." (emphasis added) Therefore, services which are not specifically tailored to meet the individualized needs and goals of the resident, based on the resident's condition and the evaluation and judgment of the resident's clinicians, may not meet this aspect of the definition for covered SNF care, and we believe that internal provider rules should not seek to circumvent the
6. Accelerating Health Information Exchange in SNFs
In the FY 2015 SNF PPS proposed rule, we included a discussion of our commitment to accelerating Health Information Exchange (HIE) in SNFs. Specifically, we noted that the Department is committed to accelerating HIE through the use of electronic health records (EHRs) and other types of health information technology across the broader care continuum through a number of initiatives including: (1) Alignment of incentives and payment adjustments to encourage provider adoption and optimization of health information technology and HIE services through
Comment: All of the comments received on this topic supported the overall agency goal to accelerate HIE within SNFs, and among post-acute care providers generally. A few commenters urged CMS to consider potential barriers to HIE for certain providers, such as those within mountainous or rural areas where connectivity may be an issue. Other commenters also asked that CMS continue to coordinate with the
Response: We appreciate the broad support for this initiative and the helpful suggestions provided by the commenters. We will share these comments with the appropriate CMS staff and other governmental agencies to ensure they are taken into account as we continue to encourage adoption of health information technology.
7. SNF Value Based Purchasing
As noted above, on
V. Provisions of the Final Rule; Regulations Text
As discussed in section IV.B. of this final rule, we are updating the payment rates under the SNF PPS for FY 2015 as required by section 1888(e)(4)(E)(ii) of the Act. In addition, we will use the most current OMB delineations (discussed in section IV.D.1) to identify a facility's urban or rural status for the purpose of determining which set of rate tables will apply to the facility. Also, effective
With reference to the civil money penalty provisions discussed in section IV.D.4. of this final rule, as proposed we are modifying current CMS regulations to provide further clarification to states and the public regarding prior approval and appropriate use of these federally-imposed civil money penalty funds.
At SEC 488.433, civil money penalties: Uses and approval of civil money penalties imposed by CMS, we will amend the regulation to specify that civil money penalties may not be used for state management operations except for the reasonable costs that are consistent with managing the projects utilizing civil money penalty funds; specify that all activities utilizing civil money penalty funds must be approved in advance by CMS; outline specific requirements that must be included in proposals submitted for CMS approval; specify that CMP funds may not be used for projects that have not been approved by CMS; specify that states are responsible for soliciting, accepting, monitoring and tracking the results of all approved activities utilizing civil money penalties and making this information publicly available on at least an annual basis; specify that state plans must ensure that a core amount of civil money penalty funds will be held in reserve for emergencies, such as relocation of residents in the event of involuntary termination from
The revised CMS regulations will explicitly clarify the intended use of these civil money penalty funds (including the processes for prior approval of all activities using civil money penalty funds by CMS) and how CMS will address a state's use of civil money penalty funds for activities that have been disapproved by CMS or used by states for activities other than those explicitly specified in statute or regulations.
At SEC 488.433(a), we clarify that approved projects may work to improve residents' quality of life and not just quality of care. We also clarify that while states may not use funds for survey and certification operations or state expenses, they may use a reasonable amount of civil money penalty funds for the actual administration of grant awards, including the tracking, monitoring, and evaluating of approved projects. Some states have maintained that effective use and management of the civil money penalty funds requires more state oversight and planning than they are able to provide currently, and that an allowance for such management would remove a barrier to the effective use of these funds. We did not propose a monetary or numeric limit on what might be considered reasonable, although one to three percent of available funds might be considered reasonable for an established fund.
At SEC 488.433(b)(5), we clarify in a new paragraph that in extraordinary situations involving closure of a facility, civil money penalty funds may be used to pay the salary of a temporary manager when CMS concludes that it is infeasible to ensure timely payment for such a manager by the facility. We have encountered situations, for example, in which a facility is in bankruptcy and the court has frozen all funds at the very time that residents are being relocated and closure is proceeding. In another situation involving involuntary termination from
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In SEC 488.433(f), we provide that CMS may withhold future disbursement of collected civil money penalty funds to a state if CMS finds that the state has not spent such funds in accordance with the statute and regulations, fails to make use of funds to benefit the quality of care or life of residents, or fails to maintain an acceptable plan approved by CMS.
VI. Collection of Information Requirements
In the
VII. Economic Analyses
A. Regulatory Impact Analysis
1. Introduction
We have examined the impacts of this final rule as required by Executive Order 12866 on Regulatory Planning and Review (
Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). Executive Order 13563 emphasizes the importance of quantifying both costs and benefits, of reducing costs, of harmonizing rules, and of promoting flexibility. This rule has been designated an economically significant rule, under section 3(f)(1) of Executive Order 12866 and a major rule under the Congressional Review Act. Accordingly, we have prepared a regulatory impact analysis (RIA) as further discussed below. Also, the rule has been reviewed by OMB.
2. Statement of Need
This final rule updates the SNF prospective payment rates for FY 2015 as required under section 1888(e)(4)(E) of the Act. It also responds to section 1888(e)(
3. Overall Impacts
This final rule sets forth updates of the SNF PPS rates contained in the SNF PPS final rule for FY 2014 (78 FR 47936). Based on the above, we estimate that the aggregate impact would be an increase of
Certain events may occur to limit the scope or accuracy of our impact analysis, as this analysis is future-oriented and, thus, very susceptible to forecasting errors due to certain events that may occur within the assessed impact time period. Some examples of possible events may include newly-legislated general
In accordance with sections 1888(e)(4)(E) and 1888(e)(5) of the Act, we update the FY 2014 payment rates by a factor equal to the market basket index percentage change adjusted by the FY 2013 forecast error adjustment (if applicable) and the MFP adjustment to determine the payment rates for FY 2015. As discussed previously, for FY 2012 and each subsequent FY, as required by section 1888(e)(5)(B) of the Act as amended by section 3401(b) of the Affordable Care Act, the market basket percentage is reduced by the MFP adjustment. The special AIDS add-on established by section 511 of the MMA remains in effect until ". . . such date as the Secretary certifies that there is an appropriate adjustment in the case mix. . . ." We have not provided a separate impact analysis for the MMA provision. Our latest estimates indicate that there are fewer than 4,355 beneficiaries who qualify for the add-on payment for residents with AIDS. The impact to
The annual update set forth in this final rule applies to SNF PPS payments in FY 2015. Accordingly, the analysis that follows only describes the impact of this single year. In accordance with the requirements of the Act, we will publish a notice or rule for each subsequent FY that will provide for an update to the SNF PPS payment rates and include an associated impact analysis.
As discussed in section IV.D.4 of this final rule, we also clarify statutory requirements and intent as specified in section 6111 of the Affordable Care Act regarding the approval and use of civil money penalties imposed by CMS. There would be no impact to states unless they failed to follow the new regulations regarding the approval and use of civil money penalty funds. In FY 2011, the approximate total amount of civil money penalties returned to the states was
4. Detailed Economic Analysis
The FY 2015 impacts appear in Table 13. Using the most recently available data, in this case FY 2013, we apply the current FY 2014 wage index and labor-related share value to the number of payment days to simulate FY 2014 payments. Then, using the same FY 2013 data, we apply the FY 2015 wage index, as discussed in section IV.D.1 of this final rule, and labor-related share value to simulate FY 2015 payments. We tabulate the resulting payments according to the classifications in Table 13 (for example, facility type, geographic region, facility ownership), and compare the difference between current and proposed payments to determine the overall impact. The breakdown of the various categories of data in the table follows.
The first column shows the breakdown of all SNFs by urban or rural status, hospital-based or freestanding status, census region, and ownership.
The first row of figures describes the estimated effects of the various changes on all facilities. The next six rows show the effects on facilities split by hospital-based, freestanding, urban, and rural categories. The urban and rural designations are based on the location of the facility under the new OMB delineations that we are implementing beginning in FY 2015. Facilities should use these OMB delineations to identify their urban or rural status for purposes of identifying what areas of the impact table would apply to them beginning on
The second column shows the number of facilities in the impact database.
The third column shows the effect of the annual update to the wage index. This represents the effect of using the most recent wage data available, without taking into account the revised OMB delineations. That is, the impact represented in this column is solely that of updating from the FY 2014 wage index to the FY 2015 wage index without any changes to the OMB delineations. The total impact of this change is zero percent; however, there are distributional effects of the change.
The fourth column shows the effect of adopting the updated OMB delineations (as set forth in OMB Bulletin No. 13-01) for wage index purposes for FY 2015, independent of the effect of using the most recent wage data available, captured in Column 3. That is, the impact represented in this column is that of using the revised OMB delineations, and utilizing the blended wage index finalized in section IV.D.1.b.v above. The total impact of this change is zero percent; however, there are distributional effects of the change.
The fifth column shows the effect of all of the changes on the FY 2015 payments. The update of 2.0 percent (consisting of the market basket increase of 2.5 percentage points, reduced by the 0.5 percentage point MFP adjustment) is constant for all providers and, though not shown individually, is included in the total column. It is projected that aggregate payments will increase by 2.0 percent, assuming facilities do not change their care delivery and billing practices in response.
As illustrated in Table 13, the combined effects of all of the changes vary by specific types of providers and by location. For example, due to changes in this rule, providers in the rural Pacific region would experience a 4.8 percent increase in FY 2015 total payments. GOES
Table 13--RUG-IV Projected Impact to the SNF PPS for FY 2015 Number of Update wage Update OMB Total change facilities data delineations (percent) FY 2015 (percent) (percent) Group: Total 15,399 0.0 0.0 2.0 Urban 10,862 0.0 0.0 2.0 Rural 4,537 0.2 -0.2 1.9 Hospital based 574 0.1 0.0 2.1 urban Freestanding 10,288 0.0 0.0 2.0 urban Hospital based 640 0.2 -0.3 1.9 rural Freestanding 3,897 0.2 -0.2 1.9 rural Urban by region: New England 803 0.7 0.0 2.7 Middle 1,490 0.0 0.2 2.1 Atlantic South Atlantic 1,853 -0.3 0.0 1.7 East North 2,054 0.0 0.0 2.0 Central East South 544 -0.7 0.1 1.3 Central West North 889 -0.1 0.1 2.0 Central West South 1,293 -0.7 0.0 1.3 Central Mountain 501 0.2 0.0 2.2 Pacific 1,429 0.5 0.0 2.5 Outlying 6 0.8 -0.1 2.6 Rural by region: New England 144 0.5 0.1 2.6 Middle 228 1.6 -1.6 2.0 Atlantic South Atlantic 504 -0.2 -0.2 1.6 East North 925 -0.1 0.0 2.0 Central East South 533 -0.3 -0.2 1.5 Central West North 1,093 0.2 -0.1 2.1 Central West South 770 0.2 -0.4 1.8 Central Mountain 235 -0.6 0.0 1.4 Pacific 105 2.8 -0.1 4.8 Outlying 0 0.0 0.0 2.1 Ownership: Government 852 0.1 -0.1 2.0 Profit 10,784 0.0 -0.1 1.9 Non-profit 3,763 0.1 -0.1 1.9 Note: The Total column includes the 2.5 percent market basket increase, reduced by the 0.5 percentage point MFP adjustment. Additionally, we found no SNFs in rural outlying areas.
5. Alternatives Considered
As described above, we estimate that the aggregate impact for FY 2015 would be an increase of
Section 1888(e) of the Act establishes the SNF PPS for the payment of Medicare SNF services for cost reporting periods beginning on or after
With regard to our implementation of the revised OMB delineations discussed in section IV.D.1 above, we considered a number of potential alternatives in the FY 2015 SNF PPS proposed rule (79 FR 25793 through 25795), which we also address here.
We considered having no transition period and fully implementing the new OMB delineations beginning in FY 2015. This would mean that we would adopt the revised OMB delineations for all providers on
First, we considered transitioning the wage index to the revised OMB delineations over a number of years in order minimize the impact of the wage index changes in a given year. However, we also believe this must be balanced against the need to ensure the most accurate payments possible, which supports the use of a shorter transition to the revised OMB delineations. As discussed above in section IV.D.1 of this final rule, we believe that using the most current OMB delineations will increase the integrity of the SNF PPS wage index by creating a more accurate representation of geographic variation in wage levels. As such, we believe that utilizing a 1-year (rather than a multiple year) transition with a blended wage index in FY 2015 strikes the best balance.
Second, we considered what type of blend would be appropriate for purposes of the transition wage index. We proposed that providers would receive a 1-year blended wage index using 50 percent of their FY 2015 wage index based on the proposed new OMB delineations and 50 percent of their FY 2015 wage index based on the FY 2014 OMB delineations. We believe that a 50/50 blend best mitigates the negative payment impacts associated with the implementation of the new OMB delineations. While we considered alternatives to the 50/50 blend, we believe this type of split balances the increases and decreases in wage index values associated with the transition, as well as provides a readily understandable calculation for providers.
Next, we considered whether or not the blended wage index should be used for all providers or for only a subset of providers, such as those providers that would experience a decrease in their respective wage index values due to implementation of the revised OMB delineations. As required in Section 1888(e)(4)(G)(ii) of the Act, the wage index adjustment must be implemented in a budget neutral manner. As such, as discussed in the FY 2015 SNF PPS proposed rule (79 FR 25785), if we were to apply the blended wage index only to those providers that would experience a decrease in their respective wage index values due to the implementation of the revised OMB delineations, the budget neutrality factor calculated based on this approach would reduce the base rates for all providers. Pursuing this type of transition policy would, in effect, aid the 21 percent of SNFs experiencing a decrease in their wage index due to the new OMB delineations (who would nevertheless also experience a decrease in their base rates under this alternative) at the expense the remaining 79 percent of SNFs, all of which would experience a decrease in their base rates due to the budget neutrality adjustment (including those SNFs experiencing either no change or an increase in their wage index under the new OMB delineations). However, as discussed in the FY 2015 SNF PPS proposed rule (79 FR 25785), if we apply the blended wage index to all providers, the resulting budget neutrality factor would not reduce the base rates for any provider. As discussed in the FY 2015 SNF PPS proposed rule, our goal in implementing a transition is to provide relief to the largest percentage of adversely affected SNFs with the least impact to the rest of facilities. We believe that the application of a one-year transition blended wage index for all providers best achieves this goal, as it mitigates the negative payment impacts of the new OMB delineations for adversely affected SNFs, without reducing the base rates for all providers.
As discussed in section IV.D.1 above, some commenters also suggested that CMS consider a 3-year transition methodology similar to that proposed in the FY 2015 IPPS proposed rule. In the FY 2015 IPPS proposed rule, CMS proposed a 3-year transition for those hospitals that are currently in urban areas that would become rural under the new OMB delineations, under which such hospitals would receive the urban wage index of the
To further address commenters' general suggestion that we utilize similar implementation policies as were proposed for hospital providers in the FY 2015 IPPS proposed rule, we also considered whether it would appropriate to apply a variation of the 3-year transition discussed above, pursuant to which all SNFs that would experience a decrease in their wage index under the new OMB delineations would receive the wage index of the
While we understand the concern raised by these commenters regarding the potential impact on the subset of SNFs that would experience a decrease in their wage index, we believe this must be weighed against the interests of and impact on all SNFs. As discussed above, and in the SNF PPS proposed rule (79 FR 25785), we believe that our proposed 1-year transition policy with a 50/50 blended wage index for all SNFs appropriately mitigates the negative payment impacts on SNFs that will experience a wage index decrease due to implementation of the new OMB delineations, while having the least impact on the rest of the facilities.
We received a comment on the potential impact of finalizing the proposals in the FY 2015 SNF PPS proposed rule, which is not otherwise addressed in prior sections of this final rule. A discussion of this comment, and our response, appears below.
Comment: In their
Response: With regard to MedPAC's proposals to eliminate the market basket update for SNFs and to implement a 4 percent reduction to the SNF PPS rates, we would note that CMS does not have the statutory authority to act on either one of these proposals at the current time.
6. Accounting Statement
As required by OMB Circular A-4 (available online at www.whitehouse.gov/sites/default/files/omb/assets/regulatory_matters_pdf/a-4.pdf), in Table 14, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this final rule. Table 14 provides our best estimate of the possible changes in
TABLE 14--Accounting Statement: Classification of Estimated Expenditures, From the 2014 SNF PPS Fiscal Year to the 2015 SNF PPS Fiscal Year Category Transfers Annualized Monetized Transfers$750 million .* From Whom to Whom? Federal Government to SNF Medicare Providers. * The net increase of$750 million in transfer payments is a result of the MFP-adjusted market basket increase of$750 million .
7. Conclusion
This final rule sets forth updates of the SNF PPS rates contained in the SNF PPS final rule for FY 2014 (78 FR 47936). Based on the above, we estimate the overall estimated payments for SNFs in FY 2015 are projected to increase by
B. Regulatory Flexibility Act Analysis
The RFA requires agencies to analyze options for regulatory relief of small entities, if a rule has a significant impact on a substantial number of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Most SNFs and most other providers and suppliers are small entities, either by their non-profit status or by having revenues of
This final rule sets forth updates of the SNF PPS rates contained in the SNF PPS final rule for FY 2014 (78 FR 47936). Based on the above, we estimate that the aggregate impact would be an increase of
Guidance issued by the
In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a Metropolitan Statistical Area and has fewer than 100 beds. This final rule would affect small rural hospitals that (1) furnish SNF services under a swing-bed agreement or (2) have a hospital-based SNF. We anticipate that the impact on small rural hospitals would be similar to the impact on SNF providers overall. Moreover, as noted in previous SNF PPS final rules (most recently the one for FY 2014 (78 FR 47968)), the category of small rural hospitals would be included within the analysis of the impact of this final rule on small entities in general. As indicated in Table 13, the effect on facilities is projected to be an aggregate positive impact of 2.0 percent. As the overall impact on the industry as a whole is less than the 3 to 5 percent threshold discussed above, the Secretary has determined that this final rule would not have a significant impact on a substantial number of small rural hospitals.
C. Unfunded Mandates Reform Act Analysis
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of
D. Federalism Analysis
Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that impose substantial direct requirement costs on state and local governments, preempts state law, or otherwise has federalism implications. This final rule would have no substantial direct effect on state and local governments, preempt state law, or otherwise have federalism implications.
List of Subjects in 42 CFR Part 488
Administrative practice and procedure, Health facilities,
For the reasons set forth in the preamble, the
PART 488--SURVEY, CERTIFICATION, AND ENFORCEMENT PROCEDURES
1. The authority citation for part 488 continues to read as follows:
Authority: Secs. 1102, 1128I and 1871 of the Social Security Act, unless otherwise noted (42 U.S.C. 1302, 1320a-7j, and 1395hh); Pub. L. 110-149, 121
2. Section 488.433 is revised to read as follows:
(a) Ten percent of the collected civil money penalty funds that are required to be held in escrow pursuant to
(b) All activities and plans for utilizing civil money penalty funds, including any expense used to administer grants utilizing civil money penalty funds, must be approved in advance by CMS and may include, but are not limited to:
(1) Support and protection of residents of a facility that closes (voluntarily or involuntarily).
(2) Time-limited expenses incurred in the process of relocating residents to home and community-based settings or another facility when a facility is closed (voluntarily or involuntarily) or downsized pursuant to an agreement with the State Medicaid agency.
(3) Projects that support resident and family councils and other consumer involvement in assuring quality care in facilities.
(4) Facility improvement initiatives, such as joint training of facility staff and surveyors or technical assistance for facilities implementing quality assurance and performance improvement programs.
(5) Development and maintenance of temporary management or receivership capability such as but not limited to, recruitment, training, retention or other system infrastructure expenses. However, as specified in
(c) At a minimum, proposed activities submitted to CMS for prior approval must include a description of the intended outcomes, deliverables, and sustainability; and a description of the methods by which the activity results will be assessed, including specific measures.
(d) Civil money penalty funds may not be used for activities that have been disapproved by CMS.
(e) The State must maintain an acceptable plan, approved by CMS, for the effective use of civil money funds, including a description of methods by which the State will:
(1) Solicit, accept, monitor, and track projects utilizing civil money penalty funds including any funds used for state administration.
(2) Make information about the use of civil money penalty funds publicly available, including about the dollar amount awarded for approved projects, the grantee or contract recipients, the results of projects, and other key information.
(3) Ensure that:
(i) A core amount of civil money penalty funds will be held in reserve for emergencies, such as relocation of residents pursuant to an involuntary termination from
(ii) A reasonable amount of funds, beyond those held in reserve under paragraph (e)(3)(i) of this section, will be awarded or contracted each year for the purposes specified in this section.
(f) If CMS finds that a State has not spent civil money penalty funds in accordance with this section, or fails to make use of funds to benefit the quality of care or life of residents, or fails to maintain an acceptable plan for the use of funds that is approved by CMS, then CMS may withhold future disbursements of civil money penalty funds to the State until the State has submitted an acceptable plan to comply with this section.
Dated:
Administrator,
Approved:
Secretary,
[FR Doc. 2014-18335 Filed 7-31-14;
BILLING CODE 4120-01-P
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