The 2019 Medicare Conditions of Participation For Medical Providers

By: Edward Neeman
Published: Tuesday, April 23 2019
Last Updated: 5 months ago

One of the primary objectives of Medicare is to ensure quality healthcare services are being delivered to beneficiaries. In order to protect American seniors and the federal healthcare program which make up the majority of beneficiaries, the CMS has put together guidelines known as the Medicare Conditions of Participation (CoP). There have been changes made over the years, but here’s where we stand in 2019.

What Are Medicare Conditions of Participation?

Medicare Conditions of Participation (CoP) are created by The Centers for Medicare and Medicaid Services (CMS). They give guidelines that various health care providers have to adhere to prior to their participation in the programs. They establish the health and safety standards required for the superior quality health care provided to Medicare beneficiaries. Medical institutions should obtain a CMS certification to portray their compliance.

Who They Benefit

For you to be eligible for Medicare, you should have attained the age of 65 years. The Medicare program is categorized into 4 parts, with each having its conditions for coverage. Part A is referred to as hospital insurance. These set standards will hence cater to inpatient care offered in hospitals, qualified nursing facilities, hospice care, etc.

Medicare CoP 2019 Guidelines

Medicare Conditions of Participation guidelines are used by state survey agencies to keep health care institutions in check. They aim to elucidate the conditions of participation for the service providers as well as surveyors in the event that the regulations are ambiguous.

Health care providers are required to portray their continued dedication towards good faith efforts as they aim to comply with the CoPs. The Medicare CoP 2019 Guidelines are followed by surveyors to determine whether the care providers comply with the set regulations.

Medicare Home Health Conditions of Participation

Home health nurses are expected to conduct a comprehensive assessment of the needs of each patient and consult a qualified physician of the proposed care plan. The HHA will conduct follow up assessments if they notice any serious changes in the patient's health (whether positive or negative). This should also be the case if the patient is readmitted to the hospital. This ensures that the care plan reflects the continued update of the patient's health status. The eventual outcome and any new treatment protocols the physician practices will also be clearly indicated.

Medicare Home Health Conditions of Participation

The quality assessment and performance improvement (QAPI) program have also been changed. The HHA is required to create a system that will be collecting, measuring, analyzing, and reporting the outcome data. The HHA will then utilize this data to make constant improvements in their performance throughout their operations.

The integrated communication system has also been changed and the HHA is expected by regulation to communicate with the patients regarding any observed change in their health and proposed care plan. The HHA should also talk to the patient's family, primary care physician, and the other doctors engaged in the care plan.

Medicare Hospice Conditions of Participation

The hospice is required by the Medicare Conditions of Participation regulations to assign a physician as the medical director of the hospice plan of each patient. This way, he or she will be able to oversee the health components of the plan and how they can provide quality care. The appointed medical director should constantly collaborate with the interdisciplinary group (IDG) to meet the needs of their patients as per their wishes.

Each professional in the interdisciplinary team should work towards ensuring that the rights of the patients are clearly outlined and upheld. Moreover, the IDG should ensure that each patient is treated following the set regulations.

The appointed hospice physician is expected by the CoP to come up with a comprehensive assessment technique that displays essential health information. He or she is also responsible for training the nurses and creating a medical profile of the patient for easy review.

Other Health Care Organizations

The other health care organizations that have been affected by the CoP changes in 2019 and should have a CMS certification include:

  • Ambulatory Surgical Centers (ASCs)
  • Community Mental Health Centers (CMHCs)
  • Comprehensive Outpatient Rehabilitation Facilities (CORFs)
  • Critical Access Hospitals (CAHs)
  • End-Stage Renal Disease Facilities
  • Federally Qualified Health Centers
  • Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
  • Organ Procurement Organizations (OPOs)
  • Portable X-Ray Suppliers
  • Programs for All-Inclusive Care for the Elderly Organizations (PACE)
  • Rehabilitation Agencies
  • Providers of Outpatient Physical Therapy and Speech-Language Pathology Services
  • Psychiatric Hospitals
  • Religious Nonmedical Health Care Institutions
  • Long Term Care Facilities
  • Transplant Centers

These health care providers will assess the conditions for coverage of their patients in order to put in place a viable care plan for them.

Proposed Changes

The changes proposed in the Medicare CoP requirements aim to make the cover simpler and service delivery seamless. This should also enhance the flexibility of the health care provider because it eliminates the onerous regulations. The health care providers will then be more oriented towards giving the patients superior quality services as per the required health and safety standards. The CMS certification should show the institution's compliance with these changes.