Which entity is responsible for determining whether a hospital qualifies for IRF PPS payment under the 60% rule?

• A. IRF Admissions Office
• B. Centers for Medicare & Medicaid Services (CMS) via policy rules
• C. Hospital finance committee
• D. State health department

Answer: (B)

The main idea here is that Medicare’s policy determines whether an IRF uses the PPS payment method under the 60% rule. CMS sets the rule, defines which diagnoses count toward the 60% threshold, and decides how the threshold is measured and applied across facilities. Hospitals collect patient data and apply those criteria, but the authority to determine PPS eligibility rests with CMS through its policy rules. If a facility doesn’t meet the 60% requirement, it doesn’t qualify for IRF PPS payments for those admissions. The other roles described—admissions intake, internal budgeting, or state licensure—don’t decide Medicare payment eligibility; CMS does.