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Presumption, Medicare A FFS, and PDPM

The Patient-Driven Payment Model (PDPM) will not create a barrier to Administrative Level of Care Presumption of Coverage.

Currently, Medicare A Fee-for-Service (FFS) affords Skilled Nursing Facilities (SNFs) an administrative presumption whereby the level of care a beneficiary needs at admission will meet the SNF level of care requirement for up to the first eight days at the SNF. To be automatically considered as meeting the level of care requirement, the Prospective Payment System (PPS) 5-day assessment needs to assign the beneficiary into one of the predetermined, more intensive RUG-IV classifiers. The purpose of the presumption is to create an efficient process for identifying those residents with the highest likelihood of meeting the leveling criteria for a Medicare A FFS stay.

There are currently 10 utilization classifications that meet the presumption criteria. These include the Rehabilitation plus Extensive Services, Rehabilitation Services, Nursing Extensive, Special Care Services, and Clinically Complex categories.

Administrative presumption will continue when PDPM replaces the RUGs classification system on Oct. 1, 2019. There are four instances when a presumption can be made:

  1. Nursing Groups – Extensive Services, Special Care, and Clinically Complex
  2. Physical and Occupational Therapy Groups – TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN, and TO
  3. Speech and Language Pathology Groups – SC, SE, SF, SH, SI, SJ, SK, and SL
  4. Non-Therapy Ancillary (NTA) Component – At the uppermost (12+) comorbidity group

To access the Centers for Medicare and Medicaid Services’ (CMS) Patient-Driven Payment Model: Frequently Asked Questions (FAQs) document, last revised on April 4, 2019, click here. For more information about upcoming PDPM educational opportunities through LeadingAge NY ProCare, click here.

Contact: Susan Chenail, schenail@leadingageny.org, 518-867-8383 ext. 116