Client Alert

Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting (CMS-3442-F) Final Rule

CMS-3442-F repeals federal minimum staffing standards for long-term care facilities while introducing new Medicaid payment rate transparency and reporting requirements for nursing facilities and ICF/IID providers beginning June 21, 2028.

Final Rule Fact Sheet
7 minutes

Key Takeaways

The Centers for Medicare & Medicaid Services (CMS) has repealed core minimum staffing requirements for long-term care facilities under CMS-3442-IFC, while leaving facility assessment obligations and new Medicaid payment rate transparency reporting requirements in place under the broader CMS-3442-F rule.

  • Minimum staffing standards repealed: The interim final rule removes the 24/7 onsite registered nurse requirement and the 0.55 RN / 2.45 nurse aide / 3.48 total nurse hours-per-resident-day standards, reinstating the pre-2024 requirement of an RN onsite at least 8 consecutive hours a day, 7 days a week, plus a full-time director of nursing — each subject to existing waiver provisions.
  • Facility Assessment Requirements remain in effect: Facilities must continue to conduct, document, and annually update (or update upon significant change) a facility-wide assessment under 42 CFR §483.71, with input from leadership, direct care staff, residents, and families.
  • New Payment Rate Transparency reporting begins June 21, 2028: States must annually report to CMS, at the facility level, the percentage of Medicaid payments — fee-for-service and managed care combined — spent on compensation for direct care workers and support staff at nursing facilities and ICF/IID facilities, with results published on a publicly accessible state website.
Key Applicability Dates

Implementation Timeline

August 8, 2024

Facility-wide assessments take effect.

Facilities must conduct, document, and review a facility-wide assessment at least annually and when there is a significant change in the facility or its resident population. The assessment must consider the resources necessary to provide competent care and include input from facility leadership, management, direct care staff, residents, and residents’ representatives.

February 2, 2026

Minimum federal staffing standards are repealed.

CMS-3442-IFC repealed the 2024 rule’s 24/7 RN requirement and minimum staffing thresholds of 0.55 RN, 2.45 nurse aide, and 3.48 total nurse staffing hours per resident day. The pre-2024 federal requirements for RN coverage and a full-time director of nursing are reinstated, subject to applicable waiver provisions.

June 21, 2028

Medicaid institutional payment transparency reporting begins.

States with Medicaid-certified nursing facilities and ICF/IID services must begin reporting facility-level information to CMS on the percentage of Medicaid payments spent on compensation for direct care workers and support staff. Reporting applies to both fee-for-service and managed care payments, and states must make the information publicly available.

Minimum Staffing Requirements Update

After significant litigation and legislation, material aspects of the Minimum Staffing Standards rule were repealed. CMS released the Repeal of Minimum Staffing Standards for Long-Term Care Facilities (CMS-3442-IFC). The interim final rule removes the definition of hours per resident day at 42 CFR § 483.5 and repeals the requirements at 42 CFR § 483.35 for a registered nurse onsite 24 hours a day, 7 days a week and for minimum staffing of 0.55 registered nurse, 2.45 nurse aide, and 3.48 total nurse staffing hours per resident day. It reinstates the pre-2024 standards: a registered nurse for at least eight consecutive hours a day, seven days a week, and a registered nurse designated as director of nursing on a full-time basis, each subject to the existing waiver provisions.

Applicable Provisions Remaining in the Minimum Staffing Rule

Although minimum staffing provisions of the rule were rescinded, other components of the staffing rule are still effective, including Facility Assessment Requirements (§483.71) and Payment Rate Transparency and Reporting Requirements (§438.72 and §442.43). The rate transparency and reporting requirements are applicable for nursing facilities (NF) and intermediate care facilities for individuals with intellectual disabilities (ICF/IID) services effective June 21, 2028, and must be reported annually.

Facility-Wide Assessments

The facility-wide assessment requires facilities to ensure they have adequate resources for competent resident care, both for normal operations and in cases of emergency. This requirement took effect in August 2024, and requires that each facility must conduct, document, and update the assessment on an annual basis or when a significant change occurs, and include input from leadership, management, direct care staff, residents, their families, and representatives.

Payment Rate Transparency

This section applies to NF and ICF/IID services. Reporting requirements for these sections are effective be June 21, 2028, and must be reported annually. States are to report facility specific information to CMS, including reporting the percentage of Medicaid payments that are spent on compensation for direct care workers and compensation for support staff. This applies to both fee-for-service and managed care payments. CMS has not yet released additional guidance regarding the transparency reporting. The key provisions of this rule include:

  • Definitions:
  • Compensation includes salary, wages, benefits (health and dental benefits, life and disability insurance, paid leave, retirement, and tuition reimbursement, etc.), and employer payroll taxes for direct care workers and support staff.
  • Direct Care Workers refer to staff providing clinical, behavioral, or personal care services directly to Medicaid beneficiaries. This includes nurses, aides, social workers, activities staff, therapists, personal care attendants, direct support professionals, medication and feeding assistants, and others providing daily living assistance.
  • Support Staff are individuals who maintain the care facility’s physical environment or provide other necessary services, such as housekeeping, groundskeeping, janitorial work, food service, security guards, and transportation.
  • Excluded Costs include costs like staff training, travel expenses, and personal protective equipment.
  • Reporting Requirements:
  • States must annually report to CMS the percentage of Medicaid payments allocated to the compensation of direct care workers and support staff at the facility level, excluding specified costs (e.g., training, PPE).
  • Medicaid payments include payments from both fee-for-service (FFS) and managed care organizations (MCOs) or prepaid inpatient health plans (PIHPs), excluding payments where Medicaid is not the primary payer.
  • Data Exclusions:
  • States must exclude data from services provided by the Indian Health Service (IHS) and Tribal health programs as per legal guidelines.
  • Payments for which Medicaid is not the primary payer are excluded.
  • Excluded costs as defined should not be included in the direct care and support compensation.
  • Report Content and Methodology:
  • Reports must detail the percentage of Medicaid payments spent on compensation for direct care workers and support staff for each nursing facility and ICF/IID.
  • Payments include base and supplemental payments.
  • States must follow reporting methodologies and formats provided by CMS.
  • Additional guidance will be released regarding reporting for contracted services.
  • Website Requirements:
  • States must maintain a publicly accessible website to display reporting results, with labels and links that are clear and easy to understand.
  • Websites must provide information about free assistance, oral interpretation, translation services, and toll-free support lines for those who need help accessing the information.
  • States must verify the website’s accuracy and functionality quarterly.
  • CMS Reporting Obligations:
  • CMS is required to publish the reported results on its website for public access.


How Myers & Stauffer Can Help

Preparing States for Medicaid Payment Transparency

Myers & Stauffer partners with more than 30 states to establish NF Medicaid rates, perform NF cost report reviews, process minimum data set (MDS) case-mix information, and/or consult on NF Medicaid reimbursement and financing issues. We also partner with eight states for ongoing HCBS rate setting and rate evaluation services.

While CMS has yet to publish final guidance related to the transparency reporting requirements, given the scope of potential data collection changes Myers & Stauffer recommends states act now to prepare for meeting the upcoming Payment Transparency reporting requirements. Our experienced team is available to assist with the following:

  • Designing cost reports or cost collection tools to collect the relevant data.
  • Evaluating and/or validating provider cost data to identify direct-care worker, support staff compensation, and excluded costs.
  • Reviewing cost reporting instructions, state service provider manuals, and other administrative code definitions to determine changes necessary to align with reporting requirements.
  • Evaluating and/or monitoring payments made to NF and ICF/ID providers.
  • Navigating complex reporting challenges for contract labor, patient share of cost payments, and other cost and payment nuances.
  • Calculating the current percentage of payments covering direct care and support staff compensation.
  • Monitoring CMS guidance and assisting states with documentation compliance.
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