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Nursing and Allied Health (NAH) Add-On Payment and Graduate Medical Education (GME) Payment Reduction for Medicare Advantage (MA)
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Overview of CR 11642
On August 21, 2020, CMS issued Change Request (CR) 11642 , which updates certain factors for the Nursing and Allied Health (NAH) Medicare Advantage (MA) add-on payment, as well as the Graduate Medical Education (GME) MA payment reduction.
This CR 11642 updated policies first communicated in CR 2692 (May 23, 2003).
Overview of CR 13122
On March 16, 2023, CMS issued Change Request (CR) 13122 , which implemented additional changes required by Section 4143 of the Consolidated Appropriations Act of 2023. These changes only impacted NAH, and not GME. Specifically, these changes removed the $60 million annual payment limit “pool” and adjusted the “pool” factor to one calculated based on actual national data available for those specific years. This legislation and the subsequent change request only impact calendar years 2010 through 2019. The $60 million payment limit remains in effect for all other years. NOTE: This change request is superseded by CR 13337 as detailed below.
Overview of CR 13337
On September 15, 2023, CMS issued Change Request (CR) 13337 to implement the NAH policy finalized in the FFY 2024 Inpatient Prospective Payment System (IPPS) Final Rule (88 FR 59058 August 28, 2023) .
This change request supersedes the policy implemented in CR 13122. Note that this CR 13337, as well as CR 13122, only apply to hospitals with cost reporting periods spanning calendar years 2010-2019. Further, the cost report must either be open, or reopenable for this Nursing and Allied Health issue. Finally, in order to qualify for revised payment under these CRs, the hospital must have an active NAH training program that was receiving NAH interim payments as of 12/29/2022. If the NAH program was shut down, OR if the program was deemed during audit not to be eligible for traditional NAH pass-through payments, no revision will be performed under these new CRs.
The end effect of the calculation from CR 13337 is to arrive at the same NAH amount that would have originally been calculated under the original FFY 2001 NAH factors AND pool number from CR 2692. This requirement is explicitly stated in business requirement 13337.3.3 at the end of CR 13337. The detail of CR 13337 goes through a proof of how this amount ends up being even higher than the amount that would have been calculated using the revised factors and revised pool numbers from CR 13122. This accomplishes the requirement from the Consolidated Appropriations Act, Section 4143 that all NAH payment amounts previously recouped under one of the older CRs be returned to hospitals, restoring them to their NAH payment from the original CR 2692.
MACs have already issued notices of reopening for all cost reports that were reopenable as part of CR 11642, CR 13122, and CR 13337. New notices of reopening will be issued for any cost report settled since that time. Providers do not need to submit a reopening request for this. All applicable reopenings related to this project will be completed by the March 19, 2024, due date listed in the CR.
The forms linked below have been updated with a box that will allow you to revert the 2010-2019 factors to the CR 2692 amounts so that you can see the impact of the payment.
WPS Provider Education Information for CR 11642 and 13122
WPS has created a YouTube video to discuss the NAH MA add-on payment and the GME MA payment reduction, as well as how this CR impacted them.
This YouTube video also discusses a new form that WPS has created for providers to calculate the NAH MA add-on payment for you. Ultimately, the amount from this form will be input on the cost report at worksheet E part A Line 53.
Two versions of this form (including an ADA compliant version) are located below. These forms incorporate the changes from both change requests:
PROVIDER VERSION – NAH Managed Care Add On Payment Calculation
ADA COMPLIANT – PROVIDER VERSION – NAH Managed Care Add On Payment Calculation
This form was discussed along with other topics during the October 2020 WPS Provider Audit Webinar. A recording of that video is available on YouTube.
Types of Providers/Cost Reports Affected by CR 11642 and 13122
- All cost reports that have not yet had a final settlement.
- All cost reports that are still reopenable (i.e. within three years from the initial NPR or the latest Reopening NPR that related directly to the NAH MA Add-on payment or GME MA Payment Reduction issue.)
- Any cost report that was appealed for this specific issue.
This CR does not apply to any other cost report that has been reopened for some other issue not directly related to the NAH MA Add-On Payment or the GME MA Payment Reduction, unless it is still reopenable for new issues as discussed in #2 above. Notices of Reopening have already been issued for all impacted cost reports from both change requests.
Important Cost Reporting Changes Due to CR 11642
Worksheet S-2 Line 60 Column 2
This has been updated to require a Y/N answer regarding whether a cost report is impacted by the CR 11642 (or subsequent CR) NAH MA add-on payment adjustment. This question must be answered to avoid a level 1 edit any time the cost report contains nursing and allied health cost at all (i.e. S-2 line 60 col. 1 is Y). This is regardless of whether the cost report actually reports the NAH MA add-on payment on worksheet E part A line 53. This new column 2 should be answered as Y for all hospitals that haven’t received a final settlement yet, or those who were appealed or reopened for the specific issues of CR 11642. However, it should be answered as N for any reopenings that are being settled for reasons not directly related to the CR 11642. Note that this cell does not impact cost report flow in any way, since the NAH MA Add-On Payment is entirely calculated outside of the cost report.
Worksheet S-2 Line 56 Column 2
This has been updated to require a Y/N answer regarding whether a cost report is impacted by the CR 11642 (or subsequent CR) GME MA payment reduction. This question must be answered to avoid a level 1 edit any time the cost report contains GME reimbursement at all (i.e. S-2 line 56 col. 1 is Y). This new column 2 should be answered as Y for all hospitals that haven’t received a final settlement yet, or those who were appealed or reopened for the specific issues of CR 11642. However, it should be answered as N for any reopenings that are being settled for reasons not directly related to the CR 11642. This cell does impact the cost report flow, as it will determine whether the old GME MA payment reduction factors flow through, or whether the new factors from CR 11642 are used.
Worksheet E-4 Line 29.01
This new line has been added to explicitly report the GME MA payment reduction factor used. This cell is only applicable for those cost reports subject to CR 11642 (as answered by S-2 Line 56 Column 2.) For all cost reports that are not subject to the change, this new line will be left blank and the original reduction factor of 14.13% will continue to be applied behind the scenes in the calculation of the reduction on line 30.
Worksheet E-4 Lines 26-30 (subscripted columns 2 and 2.01)
Due to the CR 11642 factors being calendar year based, there is now a need to split the Medicare Advantage days from the PS&R Report Type 118 at 12/31 each year. This only applies when worksheet S-2 line 56, column 2 is answered as Y (subject to CR 11642.)
global-tags: J8A,J5A,Fees and Reimbursement,Nursing and Allied Health (NAH),Nursing and Allied Health (NAH),Audit
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