This bill ensures that long-term care hospitals receive appropriate Medicare payments for treating seniors with critical conditions by exempting certain high-acuity cases from site-neutral payment rules.
Kevin Hern
Representative
OK-1
The "Securing Access to Care for Seniors in Critical Condition Act of 2025" amends the Social Security Act to change Medicare payment rules for long-term care hospitals. Beginning October 1, 2026, hospitals will not be subject to site-neutral payment rules for patients discharged under specific high-severity diagnosis groups. This adjustment aims to ensure adequate financial support for hospitals treating the most critical patients.
Medicare Payment Boost for Hospitals Treating Critically Ill Seniors Kicks Off in 2026
The "Securing Access to Care for Seniors in Critical Condition Act of 2025" tweaks Medicare payment rules for long-term care hospitals. Starting October 1, 2026, hospitals will get a break from the usual "site-neutral" payment rates when treating very sick patients.
Changing the Payment Game
Right now, Medicare often pays long-term care hospitals (LTCHs) the same rate as regular acute-care hospitals for similar services. This bill changes that for patients classified under a specific billing code (MS-LTC-DRG) with a "relative weight" of 0.8 or higher. Think of "relative weight" as a measure of how complex and resource-intensive a patient's care is. The higher the weight, the sicker the patient, and the more expensive the care. Under this new rule, if a patient's case hits that 0.8 threshold, the hospital gets paid under a different, potentially higher, rate structure.
Real-World Impact: Keeping Beds Open
Imagine a small-town LTCH where many patients are seniors with multiple chronic conditions. If a lot of those patients meet the 0.8+ criteria, the hospital could see a significant revenue bump. This could mean the difference between keeping beds open and cutting back services. For a construction worker recovering from a major accident, or a retired teacher with a complex respiratory illness, this could mean staying closer to home for specialized, long-term care. (SEC. 2)
The Fine Print: Avoiding the Upcoding Trap
While the bill aims to help hospitals that handle tough cases, there's always the risk of "upcoding." That's where a hospital might try to classify more patients under those higher-weighted codes to get more money. Medicare will likely need to keep a close eye on billing practices to make sure this doesn't become a widespread problem.
Connecting the Dots
This bill is a targeted fix to the broader system of Medicare payments. It acknowledges that some hospitals—those dealing with the sickest of the sick—face unique financial pressures. By adjusting the payment rules, the bill aims to ensure these facilities can continue providing critical care to the seniors who need it most.