Understanding the SASH Program Funding Model
The Support and Services at Home (SASH) program is an integrated model designed to help seniors in assisted living and affordable housing communities age in place. It uses a team of dedicated health and wellness professionals, including a wellness nurse and coordinator, to provide support for participants. A critical point of distinction is that for participants, SASH is free and insurance is not billed directly for these coordination services. Therefore, the payment for SASH services is not tied to a single, traditional billing event but is structured differently at a programmatic level.
Historical and Current SASH Funding Streams
Initially, programs like Vermont's SASH received significant support through national initiatives. From 2011 to 2016, a major funding source was the Centers for Medicare & Medicaid Services' (CMS) Multi-Payer Advanced Primary Care Practices (MAPCP) demonstration project. However, this demonstration funding ended in 2016, requiring state programs to pivot to new financing models.
In some regions, such as Vermont, SASH funding successfully transitioned to an All-Payer Accountable Care Organization (ACO) model. In this value-based payment (VBP) approach, the financial incentives are structured to reward better health outcomes and more efficient care delivery for a patient population. Instead of billing for each SASH service, the skilled nursing facility or larger health system is incentivized through savings generated by keeping patients healthier, out of the hospital, and reducing unnecessary medical costs. The SASH services act as a cost-effective way to achieve these goals, even if they aren't billed for individually.
Contrasting SASH Funding with Standard SNF Payments
To understand how skilled nursing vendors are paid for SASH services, it's crucial to first differentiate it from how SNFs are paid for their traditional medical services. For skilled care, SNFs are reimbursed primarily through the Medicare Part A Prospective Payment System (PPS).
- Medicare PPS: This system pays SNFs a per diem rate for all costs (routine, ancillary, and capital) related to services furnished to Medicare Part A beneficiaries. This is based on the Patient-Driven Payment Model (PDPM), which uses patient characteristics to determine payment rates. The services SASH provides are not covered under this traditional payment model.
- State Medicaid: State-level Medicaid programs also pay SNFs for services rendered to eligible residents, often with complex, state-specific reimbursement formulas. Again, SASH services are not typically billable through this channel either, as they are separate, non-clinical coordination services.
- Value-Based Purchasing (VBP): CMS also has a VBP program for SNFs, which withholds a small percentage of Medicare Part A payments and redistributes it as incentive payments based on performance metrics. Success in a SASH program can improve these metrics, indirectly benefiting the SNF financially, but it is not a direct payment for the SASH service itself.
A Deeper Look at Funding Sources for SASH Operations
While participants don't pay and SNFs can't bill directly, the cost of running a SASH program within or in partnership with a skilled nursing vendor is covered by a portfolio of funding sources. These may include:
- State-level waivers and grants: After federal demonstration funding ends, states may use waivers (like the Vermont all-payer model) or provide state-funded grants to continue the program.
- Federal grants: Other federal grants, potentially from sources like the Department of Housing and Urban Development (HUD) or others focusing on supportive housing for the elderly, could contribute to funding.
- Foundations and non-profits: Various foundations and non-profit organizations focused on senior health and well-being provide grants and financial support for programs that align with their mission.
- Contributions from partner organizations: In a multi-organizational approach, partner organizations—such as housing providers, Area Agencies on Aging, and health systems—may contribute funding or in-kind services.
SNF Payments vs. SASH Program Funding
| Feature | Standard Skilled Nursing Facility (SNF) Payments | SASH Program Funding |
|---|---|---|
| Payment Mechanism | Primarily fee-for-service (FFS), per-diem rates, or bundled payments. | Programmatic grants, government waivers, and value-based incentives. |
| Billed Entity | Medicare, Medicaid, or private insurance directly. | No direct billing to participants or insurance. |
| Covered Services | Medical, clinical, and rehabilitative care (e.g., nursing, therapies, medications, room & board). | Non-clinical care coordination, wellness support, and social engagement services. |
| Incentive Structure | Volume-based payment (FFS) or performance-based incentives (VBP) tied to medical outcomes. | Population-health incentives for improved outcomes across a group of participants, resulting in overall cost reduction. |
| Primary Payer | CMS, State Medicaid agencies, Managed Care Organizations (MCOs). | State government, CMS through special programs/waivers, foundations, and partner organizations. |
| Financial Risk | Risk of claim denial or insufficient reimbursement for specific services. | Funding dependency on successful grant applications, waiver renewals, and programmatic results. |
The Strategic Role of SASH for Skilled Nursing Facilities
Although SNFs don't bill for SASH services, partnering with or hosting a SASH program can provide significant long-term strategic advantages. The SASH model focuses on proactive health management and social engagement, which can lead to better health outcomes for residents. For a skilled nursing facility, this means a reduced rate of costly re-hospitalizations, which is a key metric in modern VBP programs. By improving these outcomes, the SNF becomes eligible for higher incentive payments or shared savings, indirectly paying for the value provided by the SASH program.
This collaborative approach between a SNF and a SASH program ensures that residents receive holistic, person-centered care that addresses not only their medical needs but also their social and wellness needs, ultimately benefiting all parties involved. For more information on Medicare payment systems, including the Prospective Payment System for skilled nursing facilities, visit the official CMS website at cms.gov.
Conclusion: SASH Payment is Holistic, Not Transactional
The funding model for SASH services is fundamentally different from traditional healthcare billing. It shifts the focus from a transactional, fee-for-service approach to a holistic, value-based model that leverages grants, state programs, and incentives from ACOs to cover costs. While skilled nursing vendors do not bill for SASH, their participation is strategically valuable, enabling them to achieve better resident outcomes and, in turn, succeed in performance-based payment programs. This sophisticated, multi-pronged approach ensures that these vital care coordination and wellness services are sustained without adding a direct financial burden to participants or their insurance, creating a more integrated and effective care ecosystem.
