Every year, the Center for Medicare Advocacy hears from the families of Medicare beneficiaries who cannot find a nursing facility to admit them because they need costly drugs that, under current rules, facilities would have to provide to them, without charge. Under “consolidated billing” rules, a skilled nursing facility (SNF) must pay for all the care and services a resident in a Part A-covered stay needs, including all drugs. However, when the drugs, often cancer drugs, are very expensive (and sometimes more expensive than the daily rate that the facility would receive for the resident), the SNF refuses to admit the beneficiary. Only some cancer drugs and other services are currently excluded from consolidated billing.
Federal Medicare law allows SNFs to exclude from consolidated billing drugs and other services that are high cost and not usually provided by a SNF. This year, in the annual update to Medicare Part A payments to SNFs, the Centers for Medicare & Medicaid Services (CMS) explicitly solicits public comment on whether it should consider excluding additional drugs and services in any of the categories for exclusion provided by law (chemotherapy items, chemotherapy administration services, radioisotype services, customized prosthetic devices, and blood clotting factors). CMS asks for the specific HCPCS code and the rationale for exclusion from consolidated billing. See 89 Fed. Reg. 23424, at pages 23435-23436 (Apr. 3, 2024).
Comments on this request and on the proposed rule in general are due by May 28, 2024. Please also send your comments and recommendations to tedelman@MedicareAdvocacy.org.
April 25, 2024 – T. Edelman