The bill amends section 1886(m)(6)(A) of the Social Security Act to add a ‘‘high acuity’’ criterion that blocks the application of site‑neutral payments to certain discharges from long‑term care hospitals (LTCHs). A discharge meets the new exception if it is assigned an MS‑LTC‑DRG with a relative weight of at least 0.8 for the applicable fiscal year and occurs on or after October 1, 2026.
For LTCH operators, the change preserves LTCH payment treatment for patients who meet that DRG‑weight threshold; for Medicare, it narrows the reach of site‑neutral payments and could increase program spending on LTCH‑level care for high‑weighted cases. Compliance officers, coders, and CMS billing systems will need to track the new threshold and apply it on a fiscal‑year basis.
At a Glance
What It Does
The bill amends the Medicare statute to add a high‑acuity exclusion from site‑neutral payment rules for LTCH discharges. The exclusion applies when the discharge’s MS‑LTC‑DRG relative weight for the fiscal year is at least 0.8 and the discharge occurs on or after October 1, 2026.
Who It Affects
Long‑term care hospitals and their billing/coding teams, the Centers for Medicare & Medicaid Services (CMS) payment operations and auditors, acute hospitals that refer post‑acute patients, and the Medicare program budget. It also implicates consultants and vendors who manage DRG software and claims edits.
Why It Matters
By carving out higher‑weighted DRG discharges from site‑neutral reductions, the bill preserves higher LTCH payments for some patients and shapes incentives around admission, documentation, and DRG assignment. That changes payment flows for a budget‑sensitive Medicare category and raises questions about coding, monitoring, and fiscal impact.
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What This Bill Actually Does
The bill makes a surgical, narrowly worded change to Medicare’s long‑term care hospital payment rules. Today, many LTCH discharges can be subject to ‘‘site‑neutral’’ payments—which reduce LTCH payments when CMS determines that an LTCH stay could have been provided in a hospital‑based or lower‑cost setting.
This measure adds one more reason for CMS not to apply those site‑neutral rules: if a discharge is assigned an MS‑LTC‑DRG with a relative weight of 0.8 or higher for the fiscal year, it escapes site‑neutral treatment and remains reimbursed under LTCH payment rules.
Operationally, the threshold is tied to the MS‑LTC‑DRG relative weight for the fiscal year in which payment is made. That means CMS and claims processors must check the fiscal‑year specific relative weight table when adjudicating LTCH claims, rather than applying a static list of qualifying conditions.
The effective date—discharges on or after October 1, 2026—aligns the rule with fiscal year 2027 weights, so the new exclusion will begin to affect payments and claims processing in that fiscal year.The practical effects are twofold. First, some discharges that previously would have been downgraded to site‑neutral payments will now continue to receive LTCH payment amounts, which typically are higher.
Second, because the threshold is expressed as a relative weight, hospitals and coders will have an incentive to ensure MS‑LTC‑DRG assignments and accompanying documentation reflect complexity. CMS will need to build the appropriate edits, systems checks, and audit procedures to apply the new rule and to detect upcoding or misclassification that could arise from the financial incentive.Finally, the change interacts with existing exceptions (for example, the ventilator criterion) and leaves unchanged how other nonapplication rules function.
The bill does not alter the calculation of relative weights themselves, nor does it specify transitional administrative steps, so most implementation detail—how CMS operationalizes lookups, reconciliations, and audits—will fall to agency rulemaking and claims processing guidance.
The Five Things You Need to Know
The bill amends 42 U.S.C. 1395ww(m)(6)(A) to add a new ‘‘high acuity criterion’’ that exempts certain LTCH discharges from site‑neutral payments.
A discharge meets the criterion if its MS‑LTC‑DRG relative weight for the applicable fiscal year is equal to or greater than 0.8.
The exclusion applies only to discharges occurring on or after October 1, 2026 (effectively fiscal year 2027 and later).
The amendment explicitly inserts the high‑acuity criterion alongside the existing ventilator exception, expanding the statutory list of nonapplication criteria.
CMS must apply the fiscal‑year specific MS‑LTC‑DRG relative weight table when determining whether a given LTCH discharge qualifies for the exclusion.
Section-by-Section Breakdown
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Short title
This single-line provision names the bill the "Securing Access to Care for Seniors in Critical Condition Act of 2025." It has no substantive effect on payment policy but provides the public title for references to the amendment.
Inserting the high‑acuity exception into the nonapplication list
This is the operative change: the bill modifies clause (ii)(I) to add the new high‑acuity exception to the list of reasons CMS cannot apply site‑neutral payments to LTCH discharges, and then creates a new clause (v) that defines the criterion. Practically, when processing claims CMS will treat any LTCH discharge that meets the clause (v) definition as ineligible for site‑neutral reductions and therefore subject to LTCH payment rules instead. The statutory text ties qualification to the MS‑LTC‑DRG relative weight for the fiscal year, which makes the exclusion dependent on the annual weighting table used by CMS.
High‑acuity criterion: MS‑LTC‑DRG relative‑weight threshold and effective date
The new clause sets two mechanical limits: (I) the discharge must be assigned an MS‑LTC‑DRG with a relative weight >= 0.8 for that fiscal year, and (II) the discharge must occur on or after October 1, 2026. Those two elements together create a clear gating rule for claims systems. Because the statute references the fiscal‑year relative weight, CMS will apply whichever weights are in effect for the fiscal year in which the discharge occurs, creating an annual tie between the exclusion and the DRG weight schedule.
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Every bill creates winners and losers. Here's who stands to gain and who bears the cost.
Who Benefits
- Long‑term care hospitals (LTCHs) — LTCHs will see more discharges retain LTCH payment rates when the assigned MS‑LTC‑DRG relative weight meets or exceeds 0.8, preserving higher reimbursement for some complex patients.
- Patients requiring complex, high‑acuity post‑acute care — by preserving LTCH payment for higher‑weighted cases, the bill aims to support continued availability of specialized LTCH services in markets where site‑neutral cuts might otherwise reduce capacity.
- Clinical coders and revenue cycle teams at LTCHs — accurate MS‑LTC‑DRG assignment and documentation become more valuable, potentially improving revenue capture for qualifying cases.
Who Bears the Cost
- Medicare Trust Funds / Federal Medicare program — excluding more discharges from site‑neutral payment reductions will likely increase Medicare spending on LTCH care relative to current law.
- CMS payment operations and auditors — the agency must update claims‑processing logic, maintain fiscal‑year weight lookups, and expand audit scrutiny to prevent upcoding tied to the new financial incentive.
- Private payers and hospitals that transfer patients — changes in LTCH admission patterns driven by the exclusion could shift costs and referrals across acute and post‑acute settings, complicating payer negotiations and care pathways.
Key Issues
The Core Tension
The central dilemma is balancing access to specialized, high‑acuity post‑acute care against Medicare’s need to control spending and deter upcoding: the bill protects payment levels for certain complex cases to preserve LTCH capacity, but in doing so it opens an incentive for classification and documentation practices aimed at meeting a numeric DRG threshold rather than reflecting true clinical necessity.
The bill is narrowly drafted but raises several implementation and policy questions that CMS, auditors, and stakeholders will need to resolve. First, tying the exclusion to a fiscal‑year MS‑LTC‑DRG relative weight inserts an annual administrative dependency: payments hinge on the weight table in effect for that fiscal year, which can shift slightly from year to year.
That creates uncertainty for budgeting and for hospitals estimating future qualifying volumes. Second, the threshold (0.8) is numeric but contextually arbitrary—Congress sets the cutoff without accompanying analysis in the text, leaving actuarial and empirical evaluation of whether 0.8 actually distinguishes clinically complex cases to external parties.
Third, because payment incentives influence coding and admission behavior, the exclusion creates an integrity risk: hospitals may more intensively document or select MS‑LTC‑DRGs to meet the threshold. CMS will need to decide whether to strengthen pre‑payment edits, post‑payment audits, or both.
Beyond coding integrity, the statute does not provide transitional or reconciliation mechanics. It does not instruct CMS how to address cases where weights are adjusted retroactively or how to reconcile payments if a DRG or weight is later revised.
Nor does it explain interactions with other statutory programs or with state reporting regimes. Finally, the fiscal impact—while logically upward for LTCH spending relative to site‑neutral application—depends on how many discharges meet the threshold and whether behavior shifts.
Those are empirical questions that the statutory text does not resolve and that will determine whether the change meaningfully preserves LTCH capacity or primarily increases payments with limited clinical benefit.
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