Like every proposed rule before it, the Medicare Skilled Nursing Facility Prospective Payment System (SNF PPS) and Consolidated Billing Proposed Rule for Fiscal Year (FY) 2026 offers the director of nursing services (DNS) a preview of likely upcoming changes that the Centers for Medicare & Medicaid Services (CMS) may make to fee-for-service (FFS) Medicare Part A either effective Oct. 1, 2025, or in future fiscal years. These proposed changes cover multiple areas, including the Patient-Driven Payment Model (PDPM), the Skilled Nursing Facility Quality Reporting Program (SNF QRP), and the Skilled Nursing Facility Value-Based Purchasing program (SNF VBP).
CMS projects that overall SNF PPS payments will increase by approximately 2.8 percent in FY 2026 (Oct. 1, 2025 – Sept. 30, 2026) compared to FY 2025 (Oct. 1, 2024 – Sept. 30, 2025). However, urban vs. rural providers in different regions of the country are expected to see vastly different payment updates, as shown in the following excerpt from the proposed rule:
| We estimate that in FY 2026, SNFs in urban and rural areas will experience, on average, a 2.7 percent increase and 3.2 percent increase, respectively, in estimated payments compared with FY 2025. Providers in the rural Mountain region will experience the largest estimated increase in payments of approximately 5.0 percent. Providers in the urban Pacific region will experience the smallest estimated increase in payments of 1.7 percent. |
Note: Find the proposed FY 2026 PDPM case-mix adjusted federal rates and indexes for urban and rural SNFs, as well as the proposed urban and rural Core-Based Statistical Area FY 2026 SNF wage index table, here.
The following highlights of the proposed rule can help the DNS work with other key members of the interdisciplinary team and facility leadership to ensure that the SNF achieves every financial opportunity to support resident care—and that good clinical care is reflected in quality measures (QMs) across all quality programs:
SNF QRP: Most MDS section R items may end before they begin
SNFs are currently scheduled to begin data collection on Oct. 1, 2025, for five standardized patient assessment data elements in the new section R (Health-Related Social Needs) for the SNF QRP. However, CMS now proposes to remove four of these five items from the MDS and the SNF QRP in acknowledgment of “the burden associated with these items at this time.”
The following chart adapted from the proposed rule explains the proposed changes to section R and the SNF QRP:
| Proposed Section R Items to Remove Effective Oct. 1, 2025 | Proposed Section R Item to Keep Effective Oct. 1, 2025 |
| * R0310 (Living Situation) * R0320 (Food): — R03020A (Within the Past 12 Months, You Worried That Your Food Would Run Out Before You Got Money to Buy More), and — R0320B (Within the Past 12 Months, the Food You Bought Just Didn’t Last and You Didn’t Have Money to Get More) * R0330 (Utilities) | * R0340 (Transportation) |
If this proposal is finalized, SNFs will only add R0340 (Transportation), moved back to section A (Identification Information) and renumbered A1255 (Transportation), from Oct. 1 – Dec. 31, 2025 to the SNF QRP MDS items that affect payment for the FY 2027 (Oct. 1, 2026 – Sept. 30, 2027) SNF QRP program year, and then SNFs will transition to full-year reporting for subsequent fiscal years. So, the renumbered R0340—but not the other section R items—will be required reporting that counts toward each facility’s ability to meet the MDS data submission threshold.
Note: For more information about renumbering R0340 as A1255, see the MDS 3.0 Item Set Change History for October 2025 Version 1.20.1 in the ZIP file CMS-10387 here.
The MDS data submission threshold mandates that SNFs report 100 percent of the required QM data and standardized patient assessment data elements collected via the MDS on at least 90 percent of all required, submitted assessments. Failure to meet either the annual MDS data submission threshold or the separate National Healthcare Safety Network (NHSN) data submission threshold will trigger a 2 percent cut in FFS Part A payment rates in the applicable program year. That could result in a negative payment update for any provider whose annual increase is less than 2 percent.
SNFs also will continue to collect the following other social determinants of health (SDOH) as part of the SNF QRP: A1005 (Ethnicity), A1010 (Race), A1110A (What Is Your Preferred Language?), A1110B (Do You Need or Want an Interpreter to Communicate With a Doctor or Healthcare Staff?), B1300 (Health Literacy), and D0700 (Social Isolation).
SNF QRP reporting noncompliance reconsiderations
The SNF QRP reconsideration policy offers an avenue for taking action when a SNF believes that CMS’s finding of noncompliance meeting the required SNF QRP data submission thresholds is erroneous. This process is not widely used. SNFs made only 202 reconsideration requests on average per year over the last three years.
Nevertheless, CMS proposes clarifications to address inconsistencies in federal regulations about what the SNF QRP reconsideration policy allows, starting with the process for requesting an extension to file a request for reconsideration. The SNF QRP reconsideration request policy and process, defined in regulation at 42 Code of Federal Regulations (CFR) §413.360(d), allows a SNF to ask CMS to reconsider the agency’s initial determination that the SNF failed to comply with the annual SNF QRP reporting requirements. Under the current process, the SNF has 30 days after the date on the letter of noncompliance to request a reconsideration.
CMS will extend the 30-day deadline to submit a reconsideration request only “in very limited circumstances” if “the SNF requested the extension and demonstrated that extenuating circumstances existed that prevented it filing a reconsideration request by the 30-day deadline (80 FR 46460).”
To clarify the process for requesting an extension to file a request for reconsideration of a noncompliance determination, CMS proposes to take the following two steps:
- Replace “extenuating circumstances” with the term “extraordinary circumstances.” The SNF QRP has an extraordinary circumstances exception and extension (ECE) policy that allows a SNF to request an exception or extension to the SNF QRP reporting requirements for one or more quarters when the SNF experiences extraordinary circumstances beyond its control. CMS put this in federal regulation at §413.360(c) and explained what counts as extraordinary circumstances in the FY 2016 SNF PPS final rule.
CMS now proposes to align the reconsideration policy for compliance determinations with the ECE policy for the reporting requirements so that both are based on extraordinary circumstances (using the same definition in both policies). - Provide a “clearly demarcated” deadline for submitting an extension request. CMS proposes to amend the policy for reconsideration extension requests to base everything off of the 30 calendar days following the date on the letter of noncompliance received by the SNF. Everything from the extraordinary circumstance that necessitates an extension request to the request for an extension itself must occur within the 30-day period following the notice date that serves as the reconsideration request period.
CMS also proposes to notify the SNF of its final decision on the SNF’s request for an extension to file a reconsideration request “in writing via e-mail because this will allow for more expedient correspondence with the SNF, given the 30-day reconsideration timeframe.”
Finally, CMS proposes to add the specific bases for granting a reconsideration request into regulation at §413.360(d)(4) (while keeping the original text). Essentially, CMS has to determine “that the SNF was in full compliance with the SNF QRP requirements for the applicable program year,” and full compliance may include CMS “granting an exception or extension to SNF QRP reporting requirements under our ECE policy at §413.360(c)”—as long as the SNF complied with all ECE policy requirements, “including the specific scope of the exception or extension as granted by CMS.”
SNF VBP could add a reconsideration process
The SNF VBP has a two-phase review and correction process. The following chart adapted from the proposed rule explains the current process:
| Phase One | CMS accepts correction requests for 30 days after distributing the baseline period and performance period QM quarterly reports. SNFs may submit corrections to the measure results contained in those reports. The underlying data used to calculate the measure results are not subject to review and correction during this process. Note: Underlying data may only be corrected prior to the specified snapshot date for each QM. |
| Phase Two | CMS accepts correction requests for 30 days after distributing the Performance Score Report that contains the SNF performance score and ranking. SNFs may submit corrections to the SNF performance score and ranking contained in this report. |
| Review and Correction Policy | SNFs must: * Identify the error that it requests to be corrected * Explain its reason for requesting the correction, and * Submit documentation or other evidence, if available, supporting the request. Correction requests must contain all of the following: * The SNF’s CMS Certification Number (CCN). * The SNF’s name. * The correction requested. * The reason for requesting the correction, including any available evidence to support the request. CMS reviews all review and correction requests, notifies the requesting SNF of its decision, and implements any approved corrections before the affected data becomes publicly available on the Provider Data Catalog website. Note: CMS proposes to update the regulations at §413.338(f)(2) and (3) to specify that SNFs must submit their review and correction requests by sending an e-mail to the SNF VBP Program Help Desk, which is currently available at SNFVBPquestions@cms.hhs.gov. |
In this proposed rule, CMS seeks to adopt a SNF VBP reconsideration process so that SNFs may seek reconsideration of a review and correction request when they are unsatisfied with CMS’s decision on their review and correction request submitted in either Phase One or Phase Two. This “additional appeal process beyond the existing Phase One and Phase Two review and correction process” would align the SNF VBP “with other CMS quality programs, including the Expanded Home Health Value-Based Purchasing (HHVBP) Model.”
The following chart adapted from the proposed rule explains how the proposed reconsideration process works:
| Effective Date | Proposal Highlights |
| FY 2027 (Oct. 1, 2026 – Sept. 30, 2027) SNF VBP program year | * SNFs may access this additional reconsideration only if they first submit a valid review and correction request in Phase One or Phase Two and are dissatisfied with the decision. * SNFs will have 15 calendar days starting the day after the date that CMS issues a decision via e-mail on a review and correction request (as noted on that decision) submitted under Phase One or Phase Two. * SNFs that seek reconsideration of a review and correction request decision must submit their reconsideration requests via e-mail in the form and manner specified by CMS in the review and correction decision. The reconsideration request must contain all of the following: —The SNF’s CMS Certification Number (CCN). —The SNF’s name. —The issue for which the SNF submitted a review and correction request, received a review and correction request decision, and are requesting reconsideration of. —The reason why the SNF is requesting reconsideration, which can be supported by any applicable documentation or other evidence. * CMS will review the reconsideration request and provide a written decision to the SNF in a timely manner before any affected data becomes publicly available on the website CMS uses to make quality data available to the public, currently the Provider Data Catalog website. |
PDPM ICD-10 mappings
In the PDPM, ICD-10-CM codes provide a mechanism to “map” diagnoses from MDS item I0020B (ICD-10 Code/Primary Medical Condition Category) and I8000 (Additional Active Diagnoses) to the Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology (SLP), and Non-Therapy Ancillaries (NTA) components—a process that helps determine exactly how much money the SNF receives for each resident.
CMS uses rule-making with public comment to propose substantive changes to the mappings, such as changes to which clinical category or comorbidity list an ICD-10 code assigns to. In the FY 2026 SNF PPS proposed rule, the agency proposes to change the clinical category assignment for 34 ICD-10 codes that became effective on Oct. 1, 2024. Thirty-three of these changes involve switching ICD-10 codes that currently map to the Medical Management category to the Return-to-Provider (RTP) category, meaning that they would no longer support payment under PDPM when coded in I0020B effective Oct. 1, 2025.
CMS also released the FY 2026 PDPM ICD-10-CM Draft Mappings for the FY 2026 Proposed Rule. The annual draft and final updates to the mappings include substantive changes, but they also may include nonsubstantive changes that CMS does not put forth for comment. For example, nonsubstantive changes may include changes required by the ICD-10 code updates that also go into effect every Oct. 1.
RFI: CMS seeks pre-rulemaking insights on multiple topics
CMS makes four requests for information (RFIs), which seek public input before CMS potentially formulates an actual proposal, in the proposed rule. The two most relevant RFIs for the DNS cover the following topics:
- Radically revamping the SNF QRP data submission deadline. In the SNF QRP, SNFs currently have approximately 4.5 months following each quarterly data collection period to complete data submissions and to make any needed corrections. For example, the final deadline for the Jan. 1 – March 31, 2025 MDS data collection period will be Aug. 18, 2025, according to the Data Collection and Final Submission Deadlines for the FY 2027 SNF QRP.
This extended time frame for data submission is “the largest contributing factor to the nine-month lag between the end of the data collection period and when measures are publicly reported,” says CMS. The nine-month delay in getting QMs posted on Care Compare creates “aged data” that has limited relevance for prospective residents who are trying to make decisions about their care, as well as for providers that want to use the data for quality improvement.
CMS is considering reducing the data submission timeframe from 4.5 months to 45 days following the end of the quarter—a move that could cut the lag time between the end of the data collection period and public reporting by up to three months (i.e., one quarter). CMS expects that this change would result in minimal provider burden.
- Developing future SNF QRP measures focused on four core areas. CMS requests input on “the importance, relevance, appropriateness, and applicability” of each concept:
- Interoperability: Looking for information on approaches to assessing interoperability in the SNF setting, such as measures that address or evaluate the level of readiness for interoperable data exchange, or measures that evaluate the ability of data systems to securely share information across the spectrum of care.”
- Well-being: Looking for information on “tools and measures that assess for overall health, happiness, and satisfaction in life that could include aspects of emotional well-being, social connections, purpose, fulfillment, and self-care work” in the SNF setting. Well-being measures could serve double-duty in both the SNF QRP and the SNF VBP, points out CMS.
- Nutrition: Looking for information on “tools and frameworks that promote healthy eating habits, appropriate exercise, nutrition, or physical activity for optimal health, well-being, and best care for all” in the SNF setting. CMS notes that nutrition measures developed for the SNF QRP also may be valid to include in the SNF VBP measure set.
- Delirium: Looking for information on measures that “evaluate for the sudden, serious change in a person’s mental state or altered state of consciousness that may be associated with underlying symptoms or conditions.”
Note: Electronic comments on this proposed rule may be submitted here by searching for “CMS-1827-P” in the search box and then clicking on the blue “Comment” button at the bottom of the page when the proposed rule displays. Comments must be posted by 11:59 p.m. EDT on June 10, 2025.
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