Pursuant to the Center for Medicare Advocacy, on October 1, 2019, the Centers for Medicare & Medicaid Services (CMS) implemented a new payment system for Medicare-covered nursing home stays—the “Patient Driven Payment Model” (PDPM). PDPM creates new financial incentives for nursing homes and new challenges for nursing home residents. One of the biggest challenges for residents under PDPM is access to skilled therapy.

The Center for Medicare Advocacy and the Long Term Care Community Coalition have developed a new Issue Alert to help residents and their families understand the implications of PDPM as it relates to Medicare-covered skilled therapy services in nursing homes. The Issue Alert also provides information about relevant federal standards of care to help residents and families in preventing and challenging skilled therapy denials.

Under the new rules, nursing homes have a greater financial incentive under the new payment system to provide little to no therapy to residents. Making matters worse, PDPM allows nursing homes to provide 25 percent of a resident’s total therapy regime, by discipline, in group and/concurrent therapy settings without any penalty for exceeding that percentage. As a result, residents may experience both less therapy overall and less individualized therapy in particular under the new payment system.