As part of the annual proposed rule updating Medicare Part A payments to skilled nursing facilities (SNFs), the Centers for Medicare & Medicaid Services (CMS) is beginning the process of establishing nurse staffing standards for facilities, as promised by President Biden in his State of the Union address on March 1, 2022 and discussed in a White House Fact Sheet on February 28. CMS’s News Release announcing the proposed rule describes CMS as
soliciting input to help the agency establish minimum staffing requirements that nursing homes will need to meet to ensure all residents are provided safe, high-quality care, and nursing home workers have the support they need. This input will be used in conjunction with a new research study being conducted by CMS to determine the optimal level and type of nursing home staffing needs. The agency intends to issue proposed rules on a minimum staffing level requirement for nursing homes within one year.
In 17 specific questions, CMS asks for public comment on a broad range of issues related to staffing that it should consider, including evidence of projected savings from reduced hospitalizations and adverse events (Question 3), evidence that resources are spent on expenses not related to patient care (Question 4), whether minimum staffing requirements at the state level have been effective (Question 12), and, if so, which ones (Question 13), and unintended consequences (Question 15).
The proposed rule also:
- Decreases Medicare Part A payments to SNFs by approximately $320 million (CMS proposes increasing rates by $1.4 billion to reflect market basket increases, and also proposes decreasing rates by $1.7 billion to reflect recalibration of rates when the patient driven payment model (PDPM), implemented October 1, 2019, resulted in overpayments of 5%, or $1.7 billion, in Fiscal Year 2020)
- Requests information for measuring equity and how to tie health equity outcomes to SNF payments
- Updates the SNF Quality Reporting Program, seeking input on two measures (functional outcome measure, COVID-19 vaccination measure)
- Proposes changes to the SNF Value-Based Purchasing Program, identifying three new measures (healthcare associated infections requiring hospitalization; total nursing hours per resident day, discharge to community)
The notice of proposed rulemaking will be published in the Federal Register on Friday, April 15. Comments will be due by June 10, 2022.
The Center will be reviewing the proposed rule and drafting comments.
April 14, 2022 – T. Edelman
 CMS, “Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2023; Request for Information on Revising the Requirements for Long-Term Care Facilities to Establish Mandatory Minimum Staffing Levels,” CMS-1765-P (Notice of Proposed Rulemaking, unpublished PDF version displayed, Apr. 11, 2022, https://public-inspection.federalregister.gov/2022-07906.pdf
 The Nursing Home Reform Agenda was identified in White House, “Protecting Seniors and People with Disabilities by Improving Safety and Quality of Care in the Nation’s Nursing Homes” (Fact Sheet, Feb. 28, 2022), https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/. See “Biden Administration Issues Bold and Comprehensive Nursing Home Reform Agenda” (CMA Alert, Mar. 2, 2022),
 CMS, “HHS Takes Actions to Promote Safety and Quality in Nursing Homes; CMS Proposed Rule Seeks Feedback on Staffing Standards and Health Equity” (News Release, Apr. 11, 2022), https://www.cms.gov/newsroom/press-releases/hhs-takes-actions-promote-safety-and-quality-nursing-homes
 CMS, “Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2023; Request for Information on Revising the Requirements for Long-Term Care Facilities to Establish Mandatory Minimum Staffing Levels,” CMS-1765-P (Notice of Proposed Rulemaking, unpublished PDF version displayed, Apr. 11, 2022, pp. 226-229, https://public-inspection.federalregister.gov/2022-07906.pdf
 Fact Sheet, “Fiscal Year (FY) 2023 Skilled Nursing Facility Prospective Payment System Proposed Rule (CMS 1765-P” (Apr. 11, 2022), https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2023-skilled-nursing-facility-prospective-payment-system-proposed-rule-cms-1765-p