Changes to Medicare Advantage Payment Models for Skilled Nursing Facility and Home Health Care Claims

Sept. 30, 2019

On Sept. 9, 2019, we published an article related to the changes to the Centers for Medicare and Medicaid Services (CMS) Notice of Change to Reimbursement System for skilled nursing facilities (SNF) and Home Health. CMS launched new payment models for skilled nursing facilities and home health care. Blue Cross and Blue Shield of Texas (BCBSTX) is aligning its payment models with CMS for Medicare Advantage claims.

These changes will help support patient–focused, streamlined claims processes for skilled nursing facilities and home health agencies that are contracted to provide care and services for our Blue Cross Medicare Advantage (PPO)SM (MA PPO) and Blue Cross Medicare Advantage (HMO)SM (MA HMO) members.

What Is Changing?

  • Beginning Oct. 1, 2019, BCBSTX will transition to CMS’s Patient Driven Payment Model, which classifies skilled nursing facility claims into payment groups based on patient characteristics. This model replaces the Resource Utilization Group, Version IV (RUG–IV), which we will no longer support.
  • Beginning Jan. 1, 2020, BCBSTX will adopt CMS’s Patient–Driven Groupings Model for home health patients, as part of the Home Health Prospective Payment System. Under this new model, payment is based on 30–day periods rather than 60 days, and therapy service thresholds are eliminated.

Medicare Advantage providers should use the new CMS classifications when submitting claims for skilled nursing facility and home health services.

Learn More

Visit the CMS website for more information, including answers to frequently asked questions about CMS’s payment model for skilled nursing facilities. Also, refer to the CMS website for access to an interactive grouper tool and other details on the home health patient–driven groupings model.