CMS Begins SNF Data Validation Process
The Centers for Medicare & Medicaid Services (CMS) has officially begun the Skilled Nursing Facilities (SNF) Data Validation Process finalized in the Fiscal Year 2024 and 2025 SNF Prospective Payment System (PPS) rules. These audits are meant to validate Minimum Data Set (MDS) data used in the SNF Quality Reporting Program (QRP) and Value-Based Purchasing (VBP) program measures. CMS will randomly select up to 1,500 SNFs per year for audit. Selected SNFs will be notified through iQIES and will be required to provide medical records to support coding on up to 10 selected MDS assessments. SNFs that fail to comply with the validation process could see impacts to their Annual Payment Update. More information, including an overview presentation and a Frequently Asked Questions document, are available here. A training video from CMS is available here.
WIN: LeadingAge Policy Victory! New Online Provider Complaint Form for Medicare Advantage
On December 22, CMS released a memo through the Health Plan Management System (HPMS) that they have implemented an online form on CMS.gov for providers that need to report a complaint about a Medicare Advantage plan. Upon submission of the complaint, these complaints will be sent to the HPMS complaints tracking module. The form captures basic information about the complainant, beneficiary, provider, and MA plan, a complaint summary and optional fields for dates of service and claim number. The MA plans will not receive an attachment of the original provider complaint form. Provider complaints will be placed in queue in the Complaints Tracking Module and CMS will review and triage. Any complaint tied directly to a beneficiary can be submitted from any provider type. LeadingAge has been asking for a mechanism to effectively report provider complaints in meetings and in comment letters to CMS over the past several years and so we are pleased to see this step. LeadingAge will reach out to CMS to better understand the process and how the complaints will be dealt with after triage and share additional information as it becomes available. The form can be found here. The memo can be found here.
COVID and Respiratory Infection Requirements
Following a December bulletin regarding the Centers for Medicare & Medicaid Services’ (CMS’) reinforcement of COVID guidelines, LeadingAge has received many questions from providers and state partners about how to navigate COVID outbreaks when discrepancies exist between state requirements and the Centers for Disease Control & Prevention (CDC) recommendations. While some states may be advising nursing homes to follow state requirements and guidelines for resident isolation, testing, and healthcare personnel return-to-work, CMS maintains that nursing homes must continue to follow requirements at 42 CFR 483.80 that require an infection prevention and control program that is based on “accepted national standards.”
LeadingAge has previously advocated to CDC and Health & Human Services Secretary Kennedy for updated guidelines. We have also requested CMS to issue policy revisions to allow nursing homes to follow state-level guidance until CDC guidance is updated, but no policy changes have been issued. LeadingAge has notified CMS that states continue to provide advice that conflicts with CMS requirements. At this time, we recommend nursing homes continue to follow CDC guidelines while encouraging your state survey agency to reach out to CMS for clarification. For Kansas, you must report any outbreaks or clusters which includes 2 or more positives. Read more on the KDHE website: https://www.kdhe.ks.gov/2180/For-Health-Care-Providers.
President Releases The Great Healthcare Plan
On January 15, the White House released a one-page plan demanding action by Congress on lowering drug prices, lowering insurance premiums, holding big insurance companies accountable, and maximizing price transparency. In a video announcing the new plan, President Trump highlights the proposal to transition government subsidies from insurance companies to health savings accounts allowing individuals to use those funds to select their insurance. “The Great Healthcare Plan will require health insurance companies to publish the percentage of insurance claims they reject and average wait times for routine care on their websites,” the plan says. Additional proposals focus on healthcare pricing transparency, and changes to drug pricing through Most Favored Nation contracting agreements and the movement of some current prescription therapies to over-the counter availability. The plan purports to save individuals dollars in healthcare spending by increasing competition and driving responsibility to price compare onto the consumer via increased availability of cost and pricing information. LeadingAge looks forward to understanding and assessing specific proposals to carry out the plan’s components as they become available. The plan was released with an accompanying fact sheet.
Congress Proposes Legislative Fixes for the “Professional Degree” Definition
The Department of Education’s rulemaking to redefine what qualifies as a “professional degree” continues to raise concerns across certain healthcare professions and the sector itself. As proposed, the Department’s definition would exclude many fields vital to aging services—such as advanced nursing, physical and occupational therapy, social work, and physician assistant programs—from eligibility for higher federal loan limits. Put another way, the rule risks making advanced education less financially accessible to students seeking higher degrees in professions that aging services providers rely on.
Congress has taken notice, and several lawmakers have introduced bills seeking to address the implications of this rulemaking, which is still ongoing. Most directly addressing the issue, Representative Lawler (R-NY) introduced H.R. 6718 to amend the Higher Education Act to codify and expand the definition of a professional degree, explicitly naming nursing, physical therapy, occupational therapy, social work, and physician assistant programs as “professional degree” programs that qualify for the higher federal borrowing limits. Representative Harder (D‑CA) also has a related proposal. His bill, H.R. 6862, aims to delay until July 1, 2030, the implementation of new borrowing caps. Representatives Dingell (D-MI) (H.R. 6739), Kennedy (D-NY) (H.R. 6574), and Torres (D-NY) (H.R. 6677) have also contributed to the menu of legislative proposals related to the loan-limit reform. The rulemaking itself is still underway, and the Department is expected to post its Notice of Proposed Rulemaking for public comment at any time. LeadingAge will alert members when the comment window opens and will provide guidance on how to share feedback with federal regulators.
Measures Under Consideration (MUC) Update: Advance Care Planning
As reported in early January, the Partnership for Quality Measurement (PQM) released the Measures Under Consideration (MUC) List on December 15, containing a single measure under consideration for post-acute / long-term care (PAC/LTC) settings. Advance Care Planning (MUC 2025-20) was originally under consideration for the Home Health Quality Reporting Program, Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) and SNF Value-Based Purchasing (VBP) program and a public listening session was held on January 8.
The Pre-Rulemaking Measure Review PAC/LTC committee, in which LeadingAge participates, was scheduled to review and vote on this measure on January 14; however, PQM announced at the beginning of the session that the Centers for Medicare & Medicaid Services (CMS) had withdrawn the measure from consideration for PAC/LTC settings. The measure was also withdrawn from voting in many of the hospital programs and the Merit-Based Incentive Payment System during hospital and clinician committee sessions but was recommended for the Hospital Inpatient Quality Reporting Program. With regard to PAC/LTC settings, CMS intends to respecify this measure before once again submitting it to the MUC List for public input. As a reminder, the MUC List is released annually by December 1, and measures recommended through this process often appear in subsequent rulemaking, such as the SNF Prospective Payment System (PPS) and Home Health PPS rules.
CMS Releases Surveyor Standards for FY 2026
The Centers for Medicare & Medicaid Services (CMS) released its annual State Performance Standards System (SPSS) Guidance for Fiscal Year (FY) 2026 on January 13. The SPSS is the metric by which state survey agency performance is measured across CMS-certified settings and contains 10 measures for FY 2026. State survey agencies are scored as having “Met” or “Not Met” measures and must submit corrective action plans for any “Not Met” measures. Notably returning for FY 2026 is the “Nursing Home Recertification Survey Composite” measure, introduced in FY 2025 and comprised of six sub-measures:
- Number of Deficiencies per 1,000 Beds
- Percentage of Deficiency-Free Surveys
- Percentage of Surveys Identifying G, H, or I Scope and Severity
- Percentage of Surveys Identifying J, K, or L Scope and Severity
- Percentage of Surveys where 1 or more Mandatory Tasks Not Investigated
- Percentage of Surveys where 1 or more Triggered Tasks Not Investigated
While CMS explicitly states that this measure “is not an attempt to establish deficiency or investigation quotas,” it seems unlikely that the measure does not illicit such perceptions among state surveyors, particularly when the state survey agencies will be required to review data and “explore with CMS potential underlying reasons for a lower composite score and, if necessary, strategies to improve its performance on these measures in the future.”
At this time, no data is available to determine the impact of this measure on survey behaviors in FY 2025, as the FY 2025 SPSS results will not be publicly released until spring / summer 2026 and the Quality, Certification, and Oversight Reports (QCOR) website has still not been updated since the July 2025 transition of the long-term care survey process from QIES to iQIES. LeadingAge will be evaluating this data once it becomes available and determining next steps.
CMS Releases 2026 Beneficiary Profile for Medicaid
On January 16, the Centers for Medicare and Medicaid Services (CMS) released a data brief with demographic characteristics of the Medicaid population. The brief includes information, by state, on percentages of the Medicaid population enrolled in comprehensive managed care and those dually eligible for Medicare and Medicaid. Additional data shows less than 10 percent of the enrolled Medicaid population accounting for nearly 30 percent of program spending- this population is of course individuals with disabilities eligible for long-term services and supports. This group coupled with the population of people in Medicaid over age 65 accounts for a total of 20.1 percent of the population and accounts for 50.6% of Medicaid spending. The brief breaks out average spend per enrollee by eligibility pathway, with children costing an average of $4,042 in 2023, while people with disabilities incurred the highest average annual cost at $27,579 per enrollee; the spend on older adults for the same time was $19,674. The brief provides a window into how a state’s Medicaid population compares to other states. The data continues to highlight a need to focus policies on protecting older adults and people with disabilities to limit harm while protecting services vital to their ongoing wellbeing. The full profile can be reviewed here.
