SNF 2023 Proposed Rule

Advocacy for the SNF FY2023 Proposed Rule

On 4/11/2022 CMS released the FY 2023 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Proposed Rule. CMS is soliciting comments on the proposed rule through June 10, 2022, and NARA will be submitting comments and encourages our members to do the same. If you would like to submit comments regarding the Proposed Rule, please use this link. This is our opportunity to provide CMS with our feedback. Please find the comment checklist below for comment suggestions. All comments will be processed and can be posted by

In the proposed rule CMS estimates the aggregate impact of the payment policies in this proposed rule would result in a decrease of approximately $320 million in Medicare Part A payments to SNFs in FY 2023 which reflects a $1.4 billion increase from the 3.9% update to the payment rates - this is based on a 2.8% SNF market basket update plus a 1.5% point market basket forecast error adjustment and less a 0.4% point productivity adjustment. The proposed rule unfortunately includes a negative 4.6% or $1.7 billion decrease in the SNF PPS rates as a result of the proposed recalibrated parity adjustment. CMS is proposing the parity adjustment to be immediate but are taking comments on a modified approach.  While it appears that the net impact may be 0.7% decrease, this may vary greatly based on your region and ownership. Please refer to table 19 on page 238 of the rule which updates the SNF PPS rates. This does not include the impacts of QRP or sequestration on individual providers.

 Pertinent additional items proposed in the rule include:

  • Permanent Cap on Wage Index Decreases (could enhance reimbursement stability) 
  • Changes in PDPM ICD-10 Code Mappings (e.g. depression, low back pain)
  • Request for Input: Coding Infection Isolation - (possible update to allow co-horting)
  • Request for Input: Removal of some items from consolidated billing (E.g. chemo, customized prosthetics)
  • Request for Input: Revising Staffing Requirements for LTC Facilities (potential for staff turnover included in VBP)
  • Request for Input on health equity and social disparities
  • Skilled Nursing Facility Quality Reporting Program (SNF QRP) Update
  • Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program Updates (3 new measures)

Please click this link for the Proposed Rule: 2022-07906.pdf ( 

CMS Fact Sheet: Fiscal Year (FY) 2023 Skilled Nursing Facility Prospective Payment System Proposed Rule (CMS 1765-P) | CMS



Tips for Submitting Effective Comments


A comment can express simple support or dissent for a regulatory action. However, a constructive, information-rich comment that clearly communicates and supports its claims is more likely to have an impact on regulatory decision making. These tips are meant to help the public submit comments that have an impact and help agency policy makers improve federal regulations.


  • Read and understand the regulatory document you are commenting on
  • Feel free to reach out to the agency with questions
  • Be concise but support your claims
  • Base your justification on sound reasoning, scientific evidence, and/or how you will be impacted
  • Address trade-offs and opposing views in your comment
  • There is no minimum or maximum length for an effective comment
  • The comment process is not a vote – one well supported comment is often more influential than a thousand form letters

Detailed Recommendations

  1. Comment periods close at 11:59 eastern time on the date comments are due - begin work well before the deadline.
  2. Attempt to fully understand each issue; if you have questions or do not understand a part of the regulatory document, you may ask for help from the agency contact listed in the document. Note: Although the agency contact can answer your questions about the document's meaning, official comments must be submitted through the comment form.
  3. Clearly identify the issues within the regulatory action on which you are commenting. If you are commenting on a particular word, phrase or sentence, provide the page number, column, and paragraph citation from the federal register document.
  4. If a rule raises many issues, do not feel obligated to comment on every one – select those issues that concern and affect you the most and/or you understand the best.
  5. Agencies often ask specific questions or raise issues in rulemaking proposals on subjects where they are actively looking for more information. While the agency will still accept comments on any part of the proposed regulation, please keep these questions and issues in mind while formulating your comment.
  6. Although agencies receive and appreciate all comments, constructive comments (either positive or negative) are the most likely to have an influence.
  7. If you disagree with a proposed action, suggest an alternative (including not regulating at all) and include an explanation and/or analysis of how the alternative might meet the same objective or be more effective.
  8. The comment process is not a vote. The government is attempting to formulate the best policy, so when crafting a comment it is important that you adequately explain the reasoning behind your position.
  9. Identify credentials and experience that may distinguish your comments from others. If you are commenting in an area in which you have relevant personal or professional experience (i.e., scientist, attorney, fisherman, businessman, etc.) say so.
  10. Agency reviewers look for sound science and reasoning in the comments they receive. When possible, support your comment with substantive data, facts, and/or expert opinions. You may also provide personal experience in your comment, as may be appropriate. By supporting your arguments well you are more likely to influence the agency decision making.
  11. Consider including examples of how the proposed rule would impact you negatively or positively.
  12. Comments on the economic effects of rules that include quantitative and qualitative data are especially helpful.
  13. Include the pros and cons and trade-offs of your position and explain them. Your position could consider other points of view, and respond to them with facts and sound reasoning.
  14. If you are uploading more than one attachment to the comment web form, it is recommend that you use the following file titles:
    • Attachment1_
    • Attachment2_
    • Attachment3_

This standardized file naming convention will help agency reviewers distinguish your submitted attachments and aid in the comment review process.

  1. Keep a copy of your comment in a separate file – this practice helps ensure that you will not lose your comment if you have a problem submitting it using the web form.

Posted Comments

After submission, your comment will be processed by the agency and posted to At times, an agency may choose not to post a submitted comment. Reasons for not posting the comment can include:

  • The comment is part of a mass submission campaign or is a duplicate.
  • The comment is incomplete.
  • The comment is not related to the regulation.
  • The comment has been identified as spam.
  • The comment contains Personally Identifiable Information (PII) data.
  • The comment contains profanity or other inappropriate language.
  • The submitter requested the comment not be posted.

Form Letters

Organizations often encourage their members to submit form letters designed to address issues common to their membership. Organizations including industry associations, labor unions, and conservation groups sometimes use form letters to voice their opposition or support of a proposed rulemaking. Many in the public mistakenly believe that their submitted form letter constitutes a "vote" regarding the issues concerning them. Although public support or opposition may help guide important public policies, agencies make determinations for a proposed action based on sound reasoning and scientific evidence rather than a majority of votes. A single, well-supported comment may carry more weight than a thousand form letters