Federal Regulations

Nursing Home Reform Law of 1987, which is the basis for Medicare and Medicaid regulations governing care and services in nursing facilities.

Summary of this bill prepared by Hollis Turnham, Esquire, which explains the major provisions of the law.

Nursing Home Medicare coverage is explained on pages 28 and 29 of the Medicare and You Handbook, as well as in this booklet, Medicare Coverage of Skilled Nursing Facility Care.

Revised Regulations for Long-Term Care Facilities:  The federal requirements for quality of care and quality of life in nursing homes that accept Medicare or Medicaid funding, as defined in the Code of Federal Regulations for Nursing Facilities, 42CFR483 Subpart B. 

Interpretive Guidance for surveyors, which further defines the intent of the new regulations. This is a clickable PDF: Click on the desired section and document will jump to the selected guidelines.

Informative briefs highlighting some of the regulation changes enacted in the 2016 revision and update:

In-depth 2-part summary of the key changes in the regulations:

• Part 1
• Part 2

Fact sheet as to why these revisions are vital to nursing home residents.

Summary of key changes in Phase Two of the new federal regulations that took effect November 28, 2017.

Topic-specific fact sheets on the revised nursing home regulations from the National Consumer Voice for Quality Long-Term Care:

• Transfer & discharge
• Unnecessary drugs and antipsychotic medications
• Admission 
• Assessment, care planning, and discharge planning
• Involuntary transfer and discharge
• Nursing services
• Visitation rights
• Specialized rehabilitation services
• Grievances and Resident or Family Councils
• Return to Facility After Hospitalization
• Quality of Care

 The Centers for Medicare & Medicaid Services (CMS) recently issued revisions to nursing facility surveyor guidelines that explain and elaborate upon federal nursing facility regulations. Justice in Aging has created a new fact sheet to highlight the guidance’s discussion of resident rights related to medication use and facility collection actions, explaining the relevant law and the important rights confirmed by the recent guidance.  

Information about the Center for Medicare & Medicaid Services, the agency that enforces these regulations.

What Medicare surveyors look for in quality for nursing homes.

For facilities – and empowered advocates – CMS has released survey tools that can be used to measure the quality of care for residents with dementia.

Find your state’s nursing home licensing agency, certification agency, Medicare & Medicaid administrative agency, and advocacy groups.

Summary of nursing home resident rights.

The Long-Term Care Community Coalition has published a Primer on Nursing Home Quality Standards, which includes regulatory requirements considered essential to resident safety, dignity and well-being, and featuring a Table of Contents with descriptive titles and clickable hyperlinks.

While there are no federal regulations governing Assisted Living facilities, many states have regulations and “best practices”. The new York Long Term Care Community Coalition (LTCCC) has published a report on best practices in assisted living and a state-by-state comparison of assisted living requirements and policies.

Justice In Aging has released a comprehensive report describing that “quality measures” in assisted living don’t truly measure quality, summarized here. Access the accompanying webinar materials here.

The CEO of the NY Long-Term Care Community Coalition (LTCCC) testified before the Senate Special Committee on Aging Hearing on Assisted Living Facilities at a hearing on January 25, 2024. His remarks are here.

Kaiser Health News has published a report detailing the harm caused by absence of consistent, strong regulations governing assisted living for people with dementia.

 Justice in Aging has published this fact sheet explaining rights of residents in assisted living and similar care facilities that accept Medicaid Home and Community Based Services (HCBS) funding. 

A recently implemented federal regulation provides eviction protections for assisted living residents whose care in the facility is funded through Medicaid. A new Justice in Aging FAQ explains the protections, how they have been implemented by states, and how advocates can use the regulations to protect residents from eviction. 

Home & Community Based Services are governed by a variety of federal regulations depending upon age, disability, or choice of location and services needed:

• Waiver requirements
• Waivers for persons age 65 and over
• Attendant services and supports, Community First Choice
• Optional self-directed personal assistance services
• Home & community based services for the elderly and persons with disabilities 

Justice In Aging has published a primer on Home and Community Based Services through Medicaid.

Justice In Aging has a 1-page fact sheet about Medicaid-funded HCBS (Home & Community Based Services).

Information and resources regarding the new HCBS (Home and Community Based Services) settings rule and steps each state is making to comply with the new rule, featuring an Advocates Checklist which offers ideas and steps on how to get involved in a state's assessment and transition plan process, and the HCBS Worksheet for Assessing Services and Settings, which is intended to help State agencies, community members and other stakeholders in reviewing HCBS are currently provided in their states prior to submission of the State's transition plan.

Pew Family Trust discussion of the pros and cons of a new Medicaid rule requiring more individualized care planning in home-like community-based settings as alternatives to nursing homes for services for people with disabilities and the elderly.

Justice In Aging report on how the states are performing in their compliance with federal regulations requiring Person-Centered Care Planning for Medicaid Home and Community-Based Service recipients.

Often families are told their loved one cannot be served in a community-based setting because of wandering or other challenging behaviors. The Center for Medicare and Medicaid Services (CMS) has published guidance for providers instructing them how they are to meet these needs within the federal regulations.

Consumer Voice partnered with Justice In Aging on a guide to understanding this new rule and how it impacts care and services in adult day settings

and information on how you can advocate for person-centered services in adult day settings governed by these rules.

Guide to consumer rights in Medicaid-funded HCBS (Home and Community Based Services) .

Consumer Voice has published a guide to the new Home and Community Based Services rule. 

Federal Regulations. For regulations related to patient care, assessment, quality, care coordination, etc., click on sections 484.50 – 484.80 of this resource.

 The Centers for Medicare and Medicaid Services have published a user-friendly explanative guide book,  Home Health Benefits Booklet for Medicare subscribers 

The Center for Medicare Advocacy explains that home health aide services are often misrepresented and under-provided by home health agencies, and offers a case study as an example of how to advocate for needed home health aide services.

The Center for Medicare Advocacy has published a fact sheet explaining how Medicare can cover home health aide services, and describing what services these aides can perform.

The Center for Medicare Advocacy has a new factsheet on Medicare coverage of Home Health Services in light of the Jimmo court settlement.

Full federal regulations governing hospice care. Of particular interest to patients and advocates is Subpart C of this regulation, Patient Care.

 The Centers for Medicare and Medicaid Services have published a user-friendly explanative guide book,  Hospice Benefits Booklet for Medicare subscribers 

 CMA (the Center for Medicare Advocacy) has prepared a handy Quick Guide explaining when -- and what -- care is coverable under the hospice benefit, and offering other information and advocacy tips. 

Medicare Beneficiary Guides:

· Medicare Beneficiary Guide on Payment for Nursing Home Care 

· Medicare Beneficiary Guide on Payment for Home Health Services

· Medicare Beneficiary Guide on Payment for Hospice Care Services

The Center for Medicare Advocacy (CMA) has published a “primer” on Medicare coverage for Home Health Services.

Medicare must now pay for “maintenance” therapies and treatments, not just “improvement” therapies and treatments! (This has always been the standard and federal regulation, but historically Medicare has denied payment for these services.) Read about the court settlement and its implications.

If you have had a claim denied for “maintenance” therapies or treatments, here is a resource to appeal the denial of payment.

The Center for Medicare Advocacy (CMA) has issued the following information further explaining the impact of the Jimmo settlement on therapies in various care settings:

• brief covering the Jimmo V. Sebelius settlement and its impact on payment for skilled therapy care in a variety of settings. 
• fact sheet on the impact of the Jimmo v. Sebelius case on Medicare coverage for inpatient rehabilitation.
• fact sheet on Medicare coverage of Home Health Services in light of the Jimmo court settlement 

An important distinction regarding Medicare payment for therapy services is often omitted or misunderstood by providers of therapy. THERE ARE NO THERAPY “CAPS” for Medicare payment! HOWEVER, there are “thresholds” beyond which a statement of medical necessity and a review of documentation may be required. This description explains the dollar figure for the thresholds and the requirements triggered by those thresholds. See the section titled “Implementation of the Bipartisan Budget Act of 2018”.

Immediately following the CMS change in payment models for therapies in nursing facilities (“Patient-Driven Payment Model”), a large number of facilities have drastically reduced the presence of therapists. This article from the Center for Medicare Advocacy describes the change in payment model, the reduction in therapy staff, and what residents and advocates can do.

Changes in Medicare payment processes DO NOT change eligibility and coverage for skilled therapies, although they do provide incentives for providers to change their practices – and not in the interest of consumers. CMA explains HERE.

Medicare payment processes for Home Health services have also changed, but eligibility and coverage for Home Health services have not changed; as this fact sheet from CMS confirms. 

The Center for Medicare Advocacy explains that under certain conditions, residents CAN leave a skilled nursing facility for short-term visits without losing their Medicare funding for their stay. 

“Observation status” is NOT the same as inpatient admission to a hospital, and can affect one’s eligibility for Medicare coverage of not only the hospital stay, but also a skilled nursing home stay that may be needed after release from the hospital. Learn about this practice and what advocates can do to fight it in this infographic from CMA.

CMA offers a “toolkit” to learn about “observation status” and how to advocate.

A Federal Court has ruled that patients on “observation status” who are subsequently denied Medicare coverage of long-term care services have the right to appeal. Justice In Aging has prepared a press release announcing this “win”.

The Center for Medicare Advocacy (CMA) has developed a toolkit of information and tips to help empower Medicare beneficiaries and advocates to appeal unfair denials of Medicare funding for skilled nursing facility care.

CMA article expressing concern about the significant decline in appeals decisions favoring beneficiaries when claims are denied. 

Tax breaks may be available to offset buy-in to a retirement community. 

Justice In Aging sheds light on the financial impact of Medicaid’s Estate Claims practices.

Medicaid has rules safeguarding the assets of a spouse of a nursing home resident,

Nursing homes are prohibited from requesting or requiring a third party to guarantee payment for a resident's admission or continued stay. Despite this prohibition, some facilities violate the Fair Debt Collection Practices Act and the Fair Credit Reporting Act.The Consumer Voice hosted a webinar on illegal debt collection practices by nursing homes.

 Justice in Aging and the National Consumer Law Center have also published Can a Nursing Home Force a Resident’s Family and Friends to Pay the Bill?, summarizing the relevant legal framework and offering advocates and consumers tips for fighting back should a nursing facility attempt to make someone other than the resident financially liable. The resource also outlines what to look for when reading admission agreements to avoid being caught up in such a situation.   

  The Centers for Medicare & Medicaid Services (CMS) recently issued revisions to nursing facility surveyor guidelines that explain and elaborate upon federal nursing facility regulations. Justice in Aging has created a new fact sheet to highlight the guidance’s discussion of resident rights related to medication use and facility collection actions, explaining the relevant law and the important rights confirmed by the recent guidance.