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Michelle, I think the following cites might help
you-Caralyn
From Medicare General Information,
Eligibility, and Entitlement Manual, Chapter 3 - Deductibles, Coinsurance
Amounts, and Payment Limitations, http://www.cms.gov/manuals/101_general/ge101c03.asp
10.4.1 - Starting a Benefit Period - (Rev.
1, 09-11-02)
A benefit period begins with the first day (not
included in a previous benefit period) on which a patient is furnished inpatient
hospital or extended care services by a qualified provider in a month for which
the patient is entitled to hospital insurance benefits.
A provider qualified to start a benefit period is a
hospital (including a psychiatric hospital) or SNF that meets all the
requirements of the definition of such an institution. A hospital which meets
all requirements in Chapter 5, �20 of this
manual is also a qualified hospital for purposes of beginning a benefit period
when it furnishes the patient covered inpatient emergency services. Thus,
generally, the benefit period begins when covered inpatient services are
initially furnished to an entitled individual. However, the noncovered services
furnished by a nonparticipating provider can begin a spell of illness only if
the provider is a qualified provider. A qualified provider is a hospital
(including a psychiatric hospital) or a SNF which meets all requirements in the
definition of such an institution even though it may not be participating.. A
qualified hospital in Canada or Mexico is also a qualified provider for purposes
of beginning a benefit period when it furnishes covered inpatient hospital
services. If a person is in a nonqualified institution and is subsequently
transferred to a qualified hospital (general or psychiatric), his/her benefit
period begins on admission to the qualified hospital.
Admission to a qualified SNF or to the SNF level of
care in a swing bed hospital begins a benefit period even though payment for the
services cannot be made because the prior hospitalization or transfer
requirement has not been met. Inpatient care in a Religious Non-Medical Health
Care Institution (whether as hospital or extended care services) can begin or
prolong a benefit period.
10.4.4 - Definition of Inpatient for Ending
a Benefit Period - (Rev. 1, 09-11-02)
Generally, a beneficiary is an inpatient of a
hospital if the beneficiary is receiving inpatient services in the hospital
(i.e., not on an outpatient basis). The type of care actually received is not
relevant.
However, a different definition of inpatient
applies in determining the end of a benefit period for a beneficiary in a SNF.
A beneficiary is an inpatient in a SNF only if the beneficiary's care in
the SNF meets certain skilled level of care standards. (BOLDING
MINE) The beneficiary must need and receive a skilled level of
care while in the SNF. This means that in order to have been an inpatient while
in a SNF, the beneficiary must have required and received skilled services on a
daily basis which could, as a practical matter, only have been provided in a SNF
on an inpatient basis. If these provisions were not met during the prior SNF
stay, the beneficiary was not an inpatient of the SNF for purposes of prolonging
the benefit period.
Use the following presumptions for determining
whether the skilled level of care standards were met during a prior SNF
stay.
Presumption 1: A beneficiary's care in a SNF met
the skilled level of care standards if a Medicare SNF claim was paid for the
care, unless such payment was made under limitation on liability
rules.
Presumption 2: A beneficiary's care in a SNF met
the skilled level of care standards if a SNF claim was paid for the services
provided in the SNF under the special Medicare limitation on liability rules
pursuant to placement in a non-certified bed.
Presumption 3: A beneficiary's care in a SNF did
not meet the skilled level of care standards if a claim was paid for the
services provided in the SNF pursuant to the general Medicare limitation on
liability rules. (This presumption does not apply to placement in a
non-certified bed. For claims paid under these special provisions, see
Presumption 2.)
Presumption 4: A beneficiary's care in a Medicaid
nursing facility (NF) did not meet the skilled level of care standards if a
Medicaid claim for the services provided in the NF was denied on the grounds
that the services received were not at the NF level of care (even if paid under
applicable Medicaid administratively necessary days provisions which result in
payment for care not meeting the NF level of care requirements).
Presumption 5: A beneficiary's care in a SNF met
the skilled level of care standards if a Medicare SNF claim for the services
provided in the SNF was denied on grounds other than that the services were not
at the skilled level of care.
Presumption 6: A beneficiary's care in a SNF did
not meet the skilled level of care standards if a Medicare claim for the
services provided in the SNF was denied on the grounds that the services were
not at the skilled level of care and no limitation of liability payment was
made.
Presumption 7: A beneficiary's care in a SNF did
not meet the skilled level of care standards if no Medicare or Medicaid claim
was submitted by the SNF.
Presumptions 1 through 4 cannot be rebutted. Thus,
prior Medicare and Medicaid claim determinations that necessarily required a
level of care determination for the time period under consideration are binding
for purposes of a later benefit period calculation. Presumptions 5 through 7 can
be rebutted by the beneficiary showing that the level of care needed or received
is other than that which the presumption dictates.
Presumption 6 can be rebutted because the Medicare
skilled level of care definition for coverage purposes is broader than the
skilled level of care definition used here for benefit period determinations.
Specifically, the requirement referred to in Chapter 4, �40.2 regarding prior hospital care
related to the SNF care is included in the Medicare SNF coverage requirements
but is not included in the standard for benefit period determinations.
Therefore, Medicare payment could have been denied for a SNF stay on level of
care grounds (i.e., not even waiver payment was made) because of noncompliance
with that requirement, even though skilled level of care requirements for
benefit period determinations were in fact met by the SNF stay. Consequently,
when Medicare SNF payment is denied on level of care grounds, the beneficiary
must be given the opportunity to demonstrate that he/she still needed and
received a skilled level of care for purposes of benefit period
determinations.
NOTE: Effective October 1,
1990, the levels of care that were previously covered separately under the
Medicaid SNF and intermediate care facility (ICF) benefits are combined in a
single Medicaid nursing facility (NF) benefit. Thus, the Medicaid NF benefit
includes essentially the same type of skilled care covered by Medicare's SNF
benefit, but it includes less intensive care as well. This means that when a
person is found not to require at least a Medicaid NF level of care (as under
Presumption 4), it can be presumed that he or she also does not meet the
Medicare skilled level of care standards. However, since the NF benefit can
include care that is less intensive than Medicare SNF care, merely establishing
that a person does require NF level care does not necessarily mean that he or
she also meets the Medicare skilled level of care standards. Determining whether
an individual who requires NF level care also meets the Medicare skilled level
of care standards requires an actual examination of the medical evidence and
cannot be accomplished through the simple use of a presumption. Therefore, the
previous references to Medicaid claims have been deleted from those presumptions
which establish that an individual does meet the Medicare
standards.
Medicare no-payment bills submitted by a SNF result
in Medicare program payment determinations (i.e., denials). Therefore, such
no-payment bills trigger the appropriate presumptions. This also applies in any
State where the Medicaid program utilizes no-payment bills which lead to
Medicaid program payment determinations. If a SNF erroneously fails to submit a
Medicare claim (albeit a no-pay claim) when Medicare rules require such
submission, intermediaries request a SNF to submit one. Once the no-pay bill is
submitted and denied, the applicable presumption (other than presumption 7) is
triggered. If a patient is moving from a SNF level of care to a non-SNF level of
care in a facility certified to provide SNF care, occurrence code 22 (date
active care ended) is used to signify the beginning of the no-pay period on the
bill and trigger the appropriate presumptions.
Where the presumptions are rebuttable (i.e., 5
through 7), rebuttal showings are permitted at both intermediary determination
levels under 42 CFR 405, Subpart G (i.e., a rebuttal showing regarding the
status of a prior SNF stay is made at the time that an inpatient claim is
submitted and/or at the reconsideration level). Intermediaries evaluate rebuttal
documentation even if the presumption being rebutted was triggered by a Medicaid
denial.
This special rule for determining whether a
beneficiary in a SNF is an inpatient for benefit period purposes is applicable
in all cases where a prior SNF stay affects benefit period status, not only when
a beneficiary is in exhausted or copay status and is seeking to renew a benefit
period. The rule has equal application where it results in the beneficiary
starting a new benefit period and paying a new deductible without receiving an
increase in the amount of Medicare benefits paid.
From Medicare Benefit Policy Manual,
Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance,
http://www.cms.gov/manuals/102_policy/bp102c08.pdf
30 - Skilled Nursing Facility Level of Care -
General
(Rev. 1, 10-01-03)
A3-3132, SNF-214
Care in a SNF is covered if all of the following four factors are
met:
�The patient requires skilled nursing
services or skilled rehabilitation services, i.e., services that must be
performed by or under the supervision of professional or
technical personnel (see ��30.2 - 30.4); are ordered by a physician and the
services are rendered for a condition for which the patient received inpatient
hospital services or for a condition that arose while receiving care in a
SNF for a condition for which he received inpatient hospital
services
�The patient requires these skilled
services on a daily basis (see �30.6); and
�As a practical matter, considering economy
and efficiency, the daily skilled services can be provided only on an inpatient
basis in a SNF. (See �30.7.)
�The services must be reasonable and
necessary for the treatment of a patient�s illness or injury, i.e., be
consistent with the nature and severity of the individual�s illness or injury,
the individual�s particular medical needs, and accepted standards of medical
practice. The services must also be reasonable in terms of duration and
quantity.
If any one of these four factors is not met, a stay in a SNF, even though
it might include the delivery of some skilled services, is not covered. For
example, payment for a SNF level of care could not be made if a patient needs an
intermittent rather than daily skilled service.
In reviewing SNF services to determine whether the level of care
requirements are met, the intermediary first considers whether a patient needs
skilled care. If a need for a
skilled service does not exist, then the "daily" and "practical matter"
requirements are not addressed.
Eligibility for SNF Medicare A coverage has not changed with the inception
of PPS. However, the skilled criteria and the medical review process have
changed slightly. For Medicare to render payment for skilled services provided
to a beneficiary during a SNF Part A stay, the facility must complete an
MDS.
EXAMPLE
Even though the irrigation of a suprapubic catheter may be a skilled
nursing service, daily irrigation may not be "reasonable and necessary" for the
treatment of a patient�s illness or injury.
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- Re: Medicare B vs. Medicare A Corey
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- Re: Medicare B vs. Medicare A Michelle Witges
- RE: Medicare B vs. Medicare A Brenda Chance
- Re: Medicare B vs. Medicare A Carol O'Brien
- RE: Medicare B vs. Medicare A Felix, Rosalie
- Re: Medicare B vs. Medicare A Gossamer34
