Appreciating the Medicare Five-Star Nursing Home Rating System

One of the most important elder law decisions is picking the best nursing home. While this decision is often financially motivated, it’s also critical to find a facility that offers the best possible care to fit your needs. Unfortunately, not all nursing homes are capable of meeting everyone’s needs. To help process best, Medicare has implemented a five-star rating system.


The Separate Nursing Home Ratings


Not all nursing homes meet Medicare standards. After an in-depth review of a nursing home, Medicare assigns facilities with a rating based on a one to five scale with one being the worst and five being the best. Five-star ratings for nursing homes are based on the following separate categories:

  • Health inspections. This category assesses the last three years of inspections of the facility including standard surveys and any complaint surveys. Surveyors inspect nursing homes for health and safety problems and issue deficiencies.
  • Quality measures. This category is based on 16 physical and clinical measures for nursing home residents.
  • Staffing. This rating includes information about the number of average care hours provided to each resident each day at the nursing home. Increased staffing has been shown to result in better patient outcomes.
  • Exceptions. Nursing homes that have a history of severe abuse citations can not score higher than 2. Other times, facilities are simply too new to have a rating. 


Impending Changes to Nursing Home Scores


At the end of 2020, the Centers for Medicare and Medicaid Services announced that the five-star rating system will resume all updates after being paused during the COVID-19 pandemic. Due to the virus, the three domains of the rating system were held constant at varying times throughout the last 9 months due to changes to health inspection as well as certain temporary regulatory waivers. At this time, the Centers for Medicare and Medicaid Services also replaced all legacy sites. Complete updates to the rating systems were available in early 2021. Due to these updates, some providers saw changes occur to their domain ratings and five-star quality rating system.


The Importance of the Five Star Rating System


Obtaining the highest rating possible is critical to nursing homes. As awareness of the system increases, more people are relying on the five-star scale to determine which facilities to select. Some of the particular benefits of the five-star system include:


  • Patients and their loved ones can use the scale to assess nursing homes for quality.
  • Nursing home ratings can impact a facility’s ability to obtain New York State Certificates of Need.
  • When medical professionals discharge patients from hospitals, they often rely on the scale to decide where patients should be referred.
  • Insurers consider ratings when establishing service networks. Several Medicaid plans exclude nursing homes with anything less than a three-star rating.
  • New York’s Medicaid Program annually reduces nursing home reimbursement by $50 million and re-distributes these amounts to nursing homes based on ratings as well as other factors.
  • The Centers for Medicare and Medicaid Services allows waivers of the required 3-day hospital stay before Medicare pays for skilled nursing facility care for enrollees in certain Medicare accountable care organizations. The waiver requires patients to go to nursing homes with at least a three-star rating.
  • The United States Department of Housing and Urban Development is a substantial nursing home lender. The Department uses star ratings as a critical aspect of how it assesses risk.


Contact an Experienced Elder Law Attorney

Nursing homes present many nuanced legal issues. If you or your loved one need the help of an elder law attorney, contact Ettinger Law Firm today to schedule a free case evaluation.

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