November 2019
Changes to Medicare Advantage Payment Models for Skilled Nursing Facility and Home Health Care Claims
The Centers for Medicare & Medicaid Services (CMS) is launching new payment models for skilled nursing facilities and home health care. Blue Cross and Blue Shield of Illinois (BCBSIL) 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, Blue Cross Medicare Advantage (HMO)SM, Blue Cross Medicare Advantage (HMO-POS)SM and Blue Cross Community MMAI (Medicare-Medicaid)SM members.
What is Changing?
- As noted in a September News and Updates, beginning Oct. 1, 2019, BCBSIL transitioned 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, BCBSIL 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.
Providers should use the new CMS classifications when submitting claims for skilled nursing facility and home health services for the members referenced above.
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-drive groupings model.
The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to third party sources or organizations are not a representation, warranty or endorsement of such organizations. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.