From an email thread between me and the CJR folks at CMS. My basic question was:
If a resident who qualifies for the CJR bundle wants to return to his or her home SNF after hospitalization and it doesn't have three stars, do they have to pay for the SNF Stay?
There is a SNF waiver that will begin in year 2 of the final rule. In the final rule, as described further in section III.C.11., CMS will waive the 3-day rule for episodes being tested in the CJR model for performance years 2 through 5 only if the SNF is qualified as one that has an overall rating of three stars or better in the Five-Star-Quality Rating System for SNFs on the Nursing Home Compare website for at least 7 through 12 preceding months. CMS will be providing a list of SNFs that meet this requirement to hospitals participating in the CJR model prior to the waiver becoming available for CJR hospitals. In addition, in section III.F. of the final rule, we finalized policies that maintain a beneficiary’s right to choose any provider or supplier. In the final rule, as described in the regulation texts § 510.405, the hospital is required to notify the beneficiary if the hospital is discharging a beneficiary to a SNF prior to the occurrence of a 3 day hospital stay, and the beneficiary is being transferred to or is considering a SNF that would not qualify under the SNF 3-day waiver in § 510.610, that the beneficiary will be responsible for costs associated with that stay except those which would be covered by Medicare Part B during a non-covered inpatient SNF stay.
In the case you refer to the SNF waiver would not apply if the beneficiary wants to go to a SNF that is rated 2 stars or below. In section III.F of the CJR Final rule, it specifically states that the participant hospitals will notify beneficiaries of their liability should they be discharged upon a less-than-3- day stay to a SNF that does not qualify for the waiver that we are finalizing for this model, and to notify the beneficiary of possible beneficiary liability if the hospital recommends or refers the beneficiary to any other services, which it knows or should have known to be non-covered services under Medicare. This notice is in addition to any ABN or other hospital notice of non-coverage that may be required under existing regulations. Please review the final rule for further details concerning the requirements set forth in the CJR final rule. Please refer requirements laid out in the regulation text 510.405 for Discharge planning.
Note: As stated in the CJR Final rule under the regulation text 510.405, the CJR model does not restrict Medicare beneficiaries’ ability to choose any Medicare enrolled provider or supplier, or any physician or practitioner who has opted out of Medicare.
From Judy: For your residents to be be able to come back to you after hospitalization (without paying for the SNF stay themselves), if you do not have three stars or better, they need to be able to say they do not want to participate in this bundle and/or they do not want the three day stay waived. There is a hospital I am aware of that is "educating" the feeder SNFs and the slides say this: "If resident wants to discharge to a SNF with less than 3 stars, they have to pay for it themselves." This hospital fails to mention that the beneficiary can opt out entirely of the bundle and the hospital can opt out of the waiver of the three day stay for that resident.
And for the record. We all can't be three stars or better. It's a skewed bell curve. When the bottom 25% of SNFs go out of business (as predicted by some), the ones left will fill the bell curve..........AND, the bell curve is INTERSTATE, not national, but this is a national bundled payment model. The worst in one state may be three stars in another state (I have actual examples). Please, don't let your eyes glaze over with the technical details. Get to your stakeholder organization and advocate. Meanwhile, we have to fight unjust level 2 deficiencies on survey as hard as we traditionally fight level 3 or higher. Five '4 point' Ds equal one G in the points system for assigning survey stars.
The full text of the CJR model final rule is available here: http://federalregister.gov/a/2015-29438. The CJR model website, found at http://innovation.cms.gov/initiatives/cjr/, also contains information about the proposed and final rules.
Should you have further questions on this matter, please feel free to communicate with us through this email account.
Best,
Maria Agresta Workman, RN
for Comprehensive Care for Joint Replacement
for Comprehensive Care for Joint Replacement
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