Build Back Better Act: House and Senate Nursing Home Provisions Compared

The Build Back Better Act is currently under consideration in the Senate after being passed in the House of Representatives in November. Over the weekend, on December 11, the Senate Finance Committee released its draft language for the reconciliation bill, which runs 1,180 pages. Two new nursing home provisions were added to the five that were included in the House-passed bill, bringing the total to seven nursing home-specific provisions. The two new provisions center around increasing the number of facilities that participate in the Special Focus Facility program to at least 3.5 percent of all facilities (amounting to an increase from about 88 facilities to approximately 550) and providing $800 million in grant funding to states to improve staffing and infection control in long-term care institutional settings.

The Center for Medicare Advocacy has been advocating for all five of the original nursing home provisions to be included in the Senate version of the bill. We partnered with Connecticut State Long-Term Care Ombudsman, Mairead Painter, to publish this Op-Ed in The CT Mirror about our mutual support for the provisions. While we are pleased the five provisions were carried over into the Senate version (largely unaltered), we are concerned that an important aspect of the Nurse Staffing provision was eliminated. The House version called for periodic studies to identify and establish appropriate minimum staff-to-resident ratios for nursing staff in skilled nursing facilities. The House bill requires the Centers for Medicare & Medicaid Services (CMS) to update staffing regulations to reflect the minimum staffing ratios from the survey findings and recommendations. The Senate version removed the mandate that CMS update its staffing regulations appropriately. Removal of this mandate significantly reduces the impact of the Nursing Staffing provision in terms of increasing the quality of care residents receive.

Below is a side-by-side comparison of the House version of the Build Back Better Act’s nursing home provisions, compared with the Senate’s current version. The current text is not final language, which means that none of these provisions are set in stone.

PROVISIONS	HOUSE	SENATE
Funding to Improve the Accuracy and Reliability of Skilled Nursing Facility Data	(Sec. 30717) Validate measures, data, and information for resident assessment data and direct care staffing information For reporting inaccurate information for FY26 – 31, reduction of payment rates by 2 percentage points Time: FY2024 – FY2031 Funding: $50M (FY22 – available through FY31)	(Sec. 122111) Validate measures, data, and information for resident assessment data and direct care staffing information For reporting inaccurate information for FY26 – 31, reduction of payment rates by 2 percentage points Time: FY2024 – FY2031 Funding: $50M (FY22 – available through FY31)
Ensuring Accurate Information on Cost Reports	(Sec. 30718) Annual audit of skilled nursing cost reports Time: Beginning 2023 – 2031 Funding: $250M (FY22 – available through FY31)	(Sec. 122112) Annual audit of skilled nursing cost reports Time: Beginning 2023 – 2031 Funding: $250M (FY22 – available through FY31)
House: Survey Improvements Senate version titled: Survey and Enforcement Improvements for Skilled Nursing Facilities and Nursing Facilities	(Sec. 30719) Conduct reviews of survey and enforcement process and identifying plans to improve (as appropriate) Provide training, tools, technical assistance, and financial support Review of state survey agencies to identify infection control and emergency preparedness deficiencies Funding: $325M (FY22 – available through FY31)	(Sec. 122113) Conduct reviews of survey and enforcement process and identifying plans to improve (as appropriate) Provide training, tools, technical assistance, and financial support Review of state survey agencies to identify infection control and emergency preparedness deficiencies Funding: $325M (FY22 – available through FY31)
Nurse Staffing Requirements Senate version titled: Nurse Staffing	(Sec. 30720) Conduct study on appropriateness of establishing minimum staff to resident ratios for nursing staff for skilled nursing facilities Timeline: No later than 3 years after bill passage and no less frequently than once every 5 years after initial survey No later than 1 year after report, CMS update staffing regulations to reflect appropriate minimum staffing ratios from the survey recommendations, using the appropriated funds Funding: $50M (FY22 – available through FY31)	(Sec. 122114) Conduct study on appropriateness of establishing minimum staff to resident ratios for nursing staff for skilled nursing facilities Timeline: No later than 3 years after bill passage and no less frequently than once every 5 years after initial survey Excluded: No later than 1 year after report, CMS update staffing regulations to reflect appropriate minimum staffing ratios from the survey recommendations, using the appropriated funds Funding: $50M (FY22 – available through FY31)
Registered Professional Nurses	(Sec. 132000) Require Registered Nurse (RN) on staff 24 hours a day, 7 days a week (Note: Increase from 8 consecutive hours a day, 7 days a week) Time: Before Oct. 1, 2024	(Sec. 122115) Require Registered Nurse (RN) on staff 24 hours a day, 7 days a week (Note: Increase from 8 consecutive hours a day, 7 days a week) Time: Before Oct. 1, 2024
Improvements to the Special Focus Facility Program	Not included in the House version, but similar language was included in the Nursing Home Improvement and Accountability Act of 2021 (S.2694/H.R.5169)	(Sec. 122116) Ensure the number of facilities participating in the special focus facility program is not less than 3.5 percent of all facilities starting no later than Oct. 1, 2023 Provide mandatory on-site consultation and educational programming for facilities participating in the special focus facility program no later than Oct. 1, 2024 Funding: $100M (FY22 – available through FY26)
Grants to Improve Staffing and Infection Control in Long-Term Care Institutional Settings	Not included in the House version, but there was a provision in the Nursing Home Improvement and Accountability Act of 2021 (S.2694/H.R.5169) that stipulated “Enhanced Funding to Support Staffing and Quality Care in Nursing Facilities”	(Sec. 122117) Grant funding for at least two of three activities: (1) Provide wage or benefit enhancements to staff who care for residents; (2) Improve and develop training and career development opportunities, including training for infection control; (3) Expand staffing for care of residents to increase staffing ratios. Funding for administrative and technical assistance costs in carrying out the above Funding: $800M (FY22 – available through Sept. 30, 2031); $3M (FY22 – available through Sept. 30, 2031)