After the 2026 SNF PPS proposed pay rule was unveiled in April and revealed an underwhelming Medicare pay hike and a broad range of other issues, regulators could have expected a wide range of comments. Stakeholders didn’t disappoint.

Provider groups and others deluged the Centers for Medicare & Medicaid Services with comments and recommendations as the 60-day comment period expired Tuesday.

John Kane, the newly installed senior vice president of reimbursement policy for the American Health Care Association, said his group supported the proposed net 2.8% increase to Medicare Part A pay rates but also asked for more, and urged numerous changes.

“As the long-term care sector continues to face rising costs and workforce challenges, we urge policymakers to take a holistic approach to funding,” Kane said in a statement emailed to McKnight’s Long-Term Care News. “Sustainable Medicare and Medicaid policies are critical to expanding access to care, enhancing quality care, and investing in improvements.”

At the head of AHCA’s wish list is a higher net market basket update in order to better keep up with actual costs. It proposes a prospective percentage add-on, rather than relying solely on the current retrospective consideration of costs. This would also help raise Medicaid payment calculations, AHCA said.

Provider association LeadingAge also stressed that “real-time” cost considerations must be taken into account, as well as known rising future expenses, such as for newly expanded PPE rules.

“Increased tariffs on the goods required for nursing homes to serve SNF residents, supply chain disruption, and other economic shifts cause an immediate strain on nursing home finances that cannot be overlooked,” LeadingAge said in comments shared with McKnight’s. 

“While the future of the Minimum Staffing Rule is uncertain, the impacts on cost have

already occurred,” added AHCA. “It is difficult to recruit and retain qualified employees, and employment in the sector remains behind pre-pandemic levels.”

AHCA said its internal analyses show nursing homes still need more than 42,700 workers to return to pre-pandemic employment levels, while other sectors have stabilized or increased their staffing levels.

The largest nursing home association in the US also continued its support for a new SNF-based wage index, and to have it allow geographic reclassification. Due to mandated formulae the proposed labor-related share of the case-mix adjusted SNF PPS pay rate for next year would actually reflect a 0.1% decrease over the current fiscal year, a move that is unconscionable under current financial conditions, AHCA said.

The American Association for Post-Acute Care Nursing also appealed to CMS to create a SNF-specific wage index, rather than relying on hospital inpatient wage data to calculate an index. Payroll-Based Journal data, which has been collected for nearly 10 years, can form a better index that “reflects true labor costs,” AAPACN leaders said.

“The result could be more equitable and accurate reimbursements, particularly for facilities struggling with rising wages or changes in their wage index,” AAPACN comments noted.

AHCA warned that without a SNF-specific wage index, costs associated with the federal nursing home staffing mandate would lead to reduced access for patients.

CMS estimates that registered nurse and aide pay will grow 2.31% per year, while the SNF patient population will remain stable over the next decade, figures that AHCA says are likely too low on both counts.

“Simply put, if SNFs cannot meet the staffing requirements because there is not sufficient funding for the staff, they will have to reduce their capacity or potentially close. It is in the Agency’s interest as well as that of the providers and patients to find an immediate solution to the problems that using the hospital wage index perpetuates,” AHCA wrote.

While AAPACN lobbied CMS to retain Section R of the MDS and to rescind its plan to remove four social determinants of health items starting with fiscal 2027, both AHCA and LeadingAge did not. The determinants relate to living situation, food and utilities and are vital for better discharge planning, said the nurses group, which suggested cutting down the consideration period for those categories from one year to just 101 days.

AHCA, however, said better use of electronic health records and information already found elsewhere, such as information that has to be collected from the patient within 30 days of admission, is sufficient to identify potential discharge planning risks. LeadingAge maintained its long-held opposition to the SDOH factors in question, noting they are not “reflective of nor impacted by the SNF stay.”

AHCA was perhaps most emphatic about its resistance to the proposed creation of quality measures gauging nursing homes’ digital readiness and capabilities. For a variety of reasons, SNFs have not been able to keep pace with hospitals’ progress, AHCA said. 

It cited federal research from 2023 that showed only 17% of hospitals were able to routinely send interoperable health information to LTPAC providers, and only 8% of the hospitals were able to receive it from them in return.

It said a “punitive one-size-fits-all interoperability quality measure” would be the wrong step at this time. 

“AHCA strongly recommends CMS does not prematurely develop and hold providers accountable to interoperability quality measures for SNFs and across all post-acute and long-term care providers without first addressing the current systemic digital divide resulting from the historical lack of federal financial and governance support otherwise afforded to hospitals and primary care providers since the enactment of the HITECH Act,” the association said, while recommending an “incremental” approach to assess the many variances in patient conditions, digital capabilities and other factors among providers.

LeadingAge said it is glad more is being sought about health information interoperability but believes CMS “might be putting the cart ahead of the horse when talking about implementing quality measures.” 

Because nursing homes and hospices were left out of the HITECH Act of 2009 that provided incentives and support for other sectors to adopt electronic health records, long-term care has been left behind. A recent annual review by LeadingAge’s CAST arm found that only about 8% of providers are utilizing EHRs to ideal full interoperability. 

“CMS should first gain an understanding of the challenges and needs of aging services providers related to health interoperability, then look for ways to support providers to get up to speed rather than employing carrot-or-stick ‘incentives, as they so often do,” LeadingAge noted.

AHCA doubled down, emphasizing “that at present, many SNF providers do not have the size and necessary human and financial resources, or technical expertise to be able to effectively implement interoperable HIT with any significant level of maturity” due to numerous external factors.

LeadingAge and AHCA also spurned the idea of creating measures of “well-being” and nutrition levels.The latter urged “extreme caution” about “extremely vague psychosocial constructions” where facilities don’t really have control over all the factors that may define conditions. 

Under plans to recategorize 34 conditions under the ICD-10 mapping system, AHCA members raised concerns about several that would no longer be covered under Part A stays, including hypoglycemia and anorexia nervosa.

AAPACN and AHCA both asked CMS to provide more time for quality reporting reconsideration requests. 

They also supported the retirement of the health equity adjustment (HEA) in the SNF Value-Based Purchasing program that was to go into effect in fiscal 2027.

In order to create fresher results yet not overburden workers, AHCA recommended that CMS consider aligning the SNF QRP Final Data Submission Deadline from 4.5 Months to 90 days — instead of the proposed 45 days (which LeadingAge supports). Among other benefits, it would align with the current 90-day MDS modification period for the CMS Nursing Home 5-Star quality measures, AHCA said.

While technology vendors cheered CMS’s questions to gather more information on providers’ health information technology usage in the original rule proposal, AHCA responded cautiously to many inquiries, repeating that many skilled nursing providers do not have sophisticated enough processes or understanding of certain HIT concepts or programs.

CMS is expected to consider stakeholder comments sent in over the last 60 days and issue its final 2026 SNF PPS rule in late July.