What Risk Does the new TERM Table Really Pose?

Have you heard about the new table initially required in the CMS Utilization Management (UM)-Focused audits? Also, known as “Table 7”, Plans need to ensure an ability to report accurate data, assess impacts, and understand risks posed by the collection of the information on the TERM table. Table 7 was included in initial CMS UM focused audits but now Table 7 appears to be inconsistently included in engagement letters. However, Plans can learn a great deal in terms of what CMS expects and will audit related to skilled nursing facility (SNF) coverage criteria.

Background

Post-hospital extended care services furnished to inpatients of a skilled nursing facility (SNF) or swing bed hospital are eligible for coverage, for a specific benefit period pursuant to applicable coverage criteria, as a basic Medicare benefit. Medicare Advantage (MA) plans have certain flexibilities in their administration of the extended care (also known as the skilled nursing facility) benefit. These include:

• Cover, as a basic benefit, SNF stays for MA enrollees that would not be otherwise covered under original Medicare, if the beneficiary had not met the required prior qualifying hospital stay.
• Offer additional days of coverage as a supplemental benefit, however MA plans may not limit the original Medicare coverage.
• Use prior authorization or concurrent review to ensure the admission and ongoing stay meet Medicare coverage rules, including medical necessity.

It is important to note these flexibilities do not otherwise change the fundamental statutory requirements for SNF coverage. Under section 1814(a)(2)(B) of the Social Security Act, a covered SNF level of care is defined in terms of those services that necessitate the involvement of skilled personnel, are needed and received on a daily basis and, as a practical matter, can be provided only in an SNF on an inpatient basis.

CMS clarified in the 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F), applicable to coverage as of January 1, 2024, the scope of coverage in the original Medicare program are applicable to MA organizations in setting the scope of basic benefits that MA plans must cover. This includes the coverage criteria for SNF care, amongst others. MA organizations can only deny SNF admission, or terminate coverage of previously authorized SNF care, for medical necessity when the MA organization determines that the Medicare FFS coverage criteria for the admission or continued stay is not met. For example, if an MA member is being discharged from a hospital and the physician orders post-acute care at a SNF because the member requires skilled nursing care on a daily basis in an institutional setting, the MA organization cannot deny coverage for the SNF care and redirect the enrollee to home health care services unless the enrollee does not meet the coverage criteria required for SNF care in 42 CFR 409.30–409.36, Section 30 of Chapter 8 of the Medicare Benefit Policy Manual, and 42 CFR 422.101(b) and (c).

Because the Medicare coverage criteria for SNF is not fully established by CMS (i.e., there is a need for additional, unspecified criteria to interpret provisions in the applicable regulation to consistently determine medical necessity), MA plans may apply internal coverage criteria or medical policies to further define criteria such as “skilled personnel”, “daily basis”, or “practical matter”, to name a few. Such internal coverage criteria must be based on current evidence in widely used treatment guidelines or clinical literature that is publicly accessible and must be approved by the UM Committee before the criteria is implemented.

Action Required

CMS expects MA organizations to make medical necessity determinations based on the individual circumstances for the enrollee, considering all information available, in a manner that most favorably provides access to services and aligns with CMS’s definition of reasonable and necessary. Available information includes, but is not limited to, the enrollee’s medical records (i.e., physician, nursing, and therapy documentation), the enrollee’s prior claims for SNF coverage, and the SNF’s Minium Data Set (MDS). Medical necessity determinations made following concurrent review for ongoing coverage of SNF services must also be made in the same manner. Enrollees should not be kept in a SNF stay if skilled services are not needed or not being provided. While SNF clinical staff should know when skilled services are no longer being provided to an enrollee and are expected to act in the best interest of enrollees regarding use of the limited SNF benefit days, it is the MA plan’s responsibility to ensure the termination of previously authorized SNF coverage is executed appropriately and timely.

When previously approved coverage of inpatient SNF services (also home health or comprehensive outpatient rehabilitation) are being discontinued, the enrollee must be notified of the termination in accordance with the regulations provided under 42 CFR 422.624. The notification of termination must be provided in writing, via a standardized notice, issued no later than two days before the services are set to terminate, and contain the enrollee’s rights to appeal the termination. This process, known as the termination of provider services, has not historically been within audit purview under the approved protocol. However, with the 2024 audit season focusing on oversight of UM requirements codified by CMS-4201-F, and the addition of Universe Table 7: Termination of Home Health Agencies, Skilled Nursing Facilities, and Comprehensive Outpatient Rehabilitation Facilities (TERM) Services Record Layout in the initial focused audits,  CMS tested MA organizations for compliance with general coverage and benefit conditions included in Traditional Medicare laws that are not superseded by laws applicable to Medicare Advantage plans. This includes, but is not limited to, criteria for coverage of post-hospital skilled nursing care under 42 CFR Part 409.

MA plans may unknowingly be at risk for the UM documentation not evidencing a compliant medical necessity determination and/or compliant notification of the reason for the discontinuation of previously covered services upon appeal to the Quality Improvement Organization (QIO). It is also imperative plan physicians can accurately describe the process MA plans use to determine medical necessity for post-acute SNF care. BluePeak has experience supporting plans in 2024 CMS UM focused audits and is available to perform a mock audit and assess your plan compliance and risk.  BluePeak is working with Plans weekly to support their audits and CMS requirements are changing- stay up on the latest information by following BluePeak on LinkedIn.  Our Subject Matter Experts (SMEs) are available to support you if you receive a CMS Program audit or UM Focused audit any Monday between now and August!