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New Issue Brief: Medicare Payment vs. Coverage for Home Health & Skilled Nursing Facility Care

The Centers for Medicare & Medicaid Services (CMS) — the federal agency responsible for administering the Medicare program — has begun implementing new Medicare payment models for both home health and skilled nursing facility care. These payment models create a different set of financial incentives for Medicare providers.Although the payment models pose a substantial risk to beneficiaries, especially those with chronic conditions and longer-term needs, CMS has made clear that PDGM and PDPM do not change Medicare coverage criteria. Thus, Medicare beneficiaries who meet the coverage criteria for home health and skilled nursing facility care must continue to receive medically reasonable and necessary services tailored to their individual needs.

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