News, Skilled Nursing Facility

CMS proposes changes to outpatient knee replacement coverage and three-day waiver rule

Two proposals published by the Centers for Medicare & Medicaid Services (CMS) last week suggest two potential changes affecting Medicare coverage and the three-day rule waiver:

  1. Medicare may cover outpatient beneficiary knee replacements; and
  2. Accountable care organizations (ACO) may no longer be required to submit documents explaining financial relationships between the organization, skilled nursing affiliates and acute care hospitals when applying for the SNF three-day rule waiver

CMS notes in the first proposal that research found that individuals who underwent procedures in an outpatient facility did not experience higher complications or readmission rates than those who underwent procedures as an inpatient. “Based on the beneficiary’s individual clinical needs and preferences,” they will still be allowed to undergo procedures in an inpatient setting, said the agency.

Public comments are open on this proposal, along with the possibility of applying this coverage change to hip replacements, until September 11, 2017.

The second proposal would not change the three-out-of-five-stars standard that SNFs are held to in order to receive patients as part of the three-day rule waiver, but would eliminate the requirement for documentation proving this rating. CMS explains that they are considering removing the requirement because they found this requirement to be burdensome when reviewing applications.

Comments are open on this second proposal until September 11, 2017.