Inside the CMS Policies That Could Improve Care, Payments for Dual-Eligible Nursing Home Residents

Given that a vast majority of long-stay nursing home residents are dual eligible for Medicare and Medicaid, residents and facilities alike can reap financial benefits while improving quality of care and reducing administrative burdens if federal and state policies better enabled a value-based care model that integrated the experiences of dual eligibles.

This is the recommendation of a report released Monday from ATI Advisory, a health care research and advisory services firm.

According to the lead author of ATI’s report, Cleo Kordomenos, who is senior analyst for ATI Advisory’s State Program & Policy Practice, the federal and state policy can be adjusted to allow for use of both Medicare and Medicaid benefits.


“The majority of long-stay nursing facility residents are dual eligible for Medicare and Medicaid, but solutions for Medicare-Medicaid integration and improving the experience of nursing facility residents rarely intersect,” said Kordomenos. “There is an opportunity to bring these policy conversations together in a way that meaningfully improves the experiences of dual eligible nursing facility residents, and for their families.”

Nearly one million dual eligible individuals live in skilled nursing facilities (SNFs). “[This] not an insignificant number,” Kordomenos said. “And yet, there’s been little attention to the need for and value of Medicare-Medicaid integration for these dual eligible nursing facility residents.

Currently, Medicare Advantage dual eligible needs plans (D-SNPs) are the only special needs plan model that allow for coordinating the use of both Medicare and Medicaid benefits for residents, Kordomenos told Skilled Nursing News.


Hence, MA-based D-SNPs offer a promising opportunity for improving quality of care for long-stay nursing facilities.

That said, as designed today across states, D-SNPs don’t generally cater to the long-stay population in SNFs, according to ATI analysts.

“CMS and states can better tailor the D-SNP care delivery model to this population,” Kordomenos said. “[F]or Medicare-Medicaid models like D-SNPs to succeed in nursing facilities, there needs to be greater alignment between Medicare and Medicaid quality measures, and there needs to be a way for nursing facilities to share credit and accountability for resident quality of care and outcomes.”

A collaboration between managed care plans and nursing facilities will also be key for a model to succeed, the report suggests.

Recommendations for CMS, states

As for policy recommendations for CMS and states to consider, ATI analysts suggest several, including a push for greater payment transparency, clinical model and quality enhancements, and reduced administrative burdens.

“Taken together, these model elements could meaningfully improve experiences for dual eligible individuals living in nursing facilities, and for their families … There is an opportunity to align financial incentives for high quality and high value care in nursing facilities through Medicare-Medicaid integration,” the report states.

To achieve policy goals, CMS could require facilities to have more transparency around financial data such as, payment for Medicaid room and board, payment for Medicare Part B therapy services, supplemental or add-on payments from the state, and payments for ancillary services.

“Such facility-level financing data would allow CMS and states to better assess payments to nursing facilities against outcomes such as quality and access, and encourage steps towards aligning financial incentives between Medicare and Medicaid,” the report states.

To enforce policy, CMS could offer enhanced or conditional payments, or apply penalties, to encourage nursing facilities to report specific data in a standard format that enables analysis. Currently CMS requires hospitals to report this data, although such sharing isn’t mandatory for nursing homes. The report notes that CMS withheld payment to hospitals until and unless hospitals met specific reporting requirements through the Hospital Inpatient Quality Reporting Program. In addition, CMS could promote reporting accountability by developing and issuing a standardized reporting template to support states. “CMS could then merge this template with data and reporting pertaining to Medicare payments to nursing facilities,” the report states.

Meanwhile, states can also take their own action on this front.

“[States can] simplify care experiences for residents and their families and reduce the administrative burden on nursing facilities by limiting the number of managed care organizations serving dual eligible nursing facility residents and establishing uniformity across managed care plans,” the analysts wrote.

Steps for SNFs

And while CMS and state policy could facilitate integrated program design across Medicare and Medicaid, there are steps nursing facilities and managed care plans can undertake to advance better quality, person-centered care for dual eligible individuals in SNFs.

“Without federal action, managed care plans can pursue risk-sharing value-based models with nursing facilities that prioritize improvements in care delivery and outcomes for dual eligible nursing facility residents,” ATI analysts suggested. “These partnerships should share accountability and credit to incentivize quality care for residents,” the report states.

In putting together the analysis, ATI Advisory used research, data analytics, and insights from various experts across the sector. The advisory firm convened several roundtables involving consumer advocates, clinicians, nursing home operators and experts from managed care plans.

“We hope our report and the policy opportunities presented within can be used to improve dual eligible individuals’ experiences in nursing facilities,” Kordomenos said.

Companies featured in this article: