CMS guidance aims to ease access to nursing home waivers for ACOs

Caregiver end of life care nursing home palliative care
The Centers for Medicare & Medicaid Services has issued new guidance on waivers for the "three-day rule" for accountable care organizations. (Getty/KatarzynaBialasiewicz)

The Centers for Medicare & Medicaid Services is making it easier for accountable care organizations that accept downside risk to obtain waivers for a rule that requires a three-day inpatient stay before a referral to a nursing home. 

CMS issued guidance (PDF) on the issue earlier this week, and in the document it outlines how Medicare Shared Savings Program (MSSP) ACOs can apply for the waivers. 

Only ACOs that are participating in or applying for MSSP’s performance-based risk tracks are eligible. To apply, ACOs must submit a list of affiliate skilled nursing facilities it intends to partner with, and these nursing homes must maintain a rating of at least three stars on Nursing Home Compare. 


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Applicants must also build communication and care management plans for these arrangements, CMS said. In addition, CMS is recognizing rural and critical-access hospitals operating under swing-bed agreements as eligible affiliates for the first time, according to the guidance. 

RELATED: Industry groups sound off on ACO program changes, but half of participants say they will stay 

CMS is also limiting the waiver’s use to patients who are prospectively attributed to the ACO, instead of added into the organization at the end of the plan year based on its performance. 

Granted waivers will take effect on July 1.  

CMS recently finalized an overhaul to MSSP, which aims to push participating providers to take on more risk. In the updated model, new “low-revenue" or physician-led ACOs will have three years to operate in a one-sided risk model, down from six. Other new ACOs will have two years with one-sided risk, and existing organizations have one year to take on additional risk. 

The move was opposed by a number of notable industry groups, including the American Medical Association, America’s Health Insurance Plan and the National Association for ACOs. 

In the new waiver guidance, CMS is also aiming to push ACOs to jump into those higher-risk tracks more quickly. Allowing easier access to these waivers would be a boon to providers who enter such arrangements, as some argue the three-day rule needlessly inflates length of stay for patients. 

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