April 5, 2024

Final Rule Suggests Continued Focus on Termination of Skilled Nursing Facility Services, Home Health and Outpatient Rehab

On April 4, CMS issued Contract Year 2025 Medicare Advantage and Part D Final Rule (CMS-4205-F). In this rule, CMS is making two significant changes related to termination of services in skilled nursing facilities, comprehensive outpatient rehabilitation facilities and home health agencies.

First, CMS is requiring that the QIO (not the Plan) review untimely fast-track appeals of a Medicare Advantage plan’s decision to terminate services in a skilled nursing facility, comprehensive outpatient rehabilitation facility or by a home health agency.

Second, CMS is eliminating the provision requiring forfeiture of an enrollee’s right to appeal a termination of services from these providers when they leave the facility.

The 2024 audit season has focused on oversight of UM requirements codified by CMS-4201-F, and the addition of Universe Table 7: Termination of Home Health Agencies, Skilled Nursing Facilities, and Comprehensive Outpatient Rehabilitation Facilities (TERM) Services Record Layout. CMS introduced Table 7 this year in some UM focus and CMS Program Audits. This review tests Plan’s compliance with medical necessity determination and/or compliant notification of the reason for the discontinuation of previously covered services. 

BluePeak has extensive experience with the UM focused audits and can help Plans ensure their term processes are compliant. Contact us today for a free consultation or our summary of the Final Rule.

Contact BluePeak

BluePeak Advisors is a division of Gallagher Benefit Services, Inc. 

Website | About UsMeet the Team | Solutions | Careers | Contact Us