RE: HMO to PPS

[Anne Burrows]

On your other post you asked what rules HMOs have to follow.  If you are 
talking about a Medicare HMO (Medicare + Choice), they must provide whatever 
would be covered by Medicare, plus whatever else the particular plan offers 
its members.   For the latter, it is best to have this clear in your 
facility's contract with the HMO.  For source information on this, go to the 
CMS.gov site and read the electronic publications that are written for 
consumers about the various Medicare plans.  They are helpful because they 
are written for lay people, and clearer than some other publications.  They 
make it clear that Medicare HMOs have to cover whatever would be covered by 
Medicare.

I sense that the woman in this post is the same one you were concerned about 
in your earlier post.   I question whether the daily injections would in 
fact entitle her to use her Medicare skilled benefit.   Does she need to be 
in a SNF to get the injections?  Is there some area of skilled monitoring or 
judgement there that would require her to be in a SNF and entitle her to use 
the benefit?  Therapy 3x a week doesn't add up to a daily skilled need 
either.  Possibly it is one of those extras the HMO offers its members, and 
if so, it should be in your contract with the HMO.

About the disenrolment and return to regular Medicare:   The day of the 
switch is day 1 for figuring the PPS schedule.  I don't know when she 
actually disenrolled, of if you are still in the window for when it is legal 
to do the 5-day, 14-day, etc.  If you are still within bounds, OK.  If not, 
you can bill at the default rate.

If a SNF resident disenrolls from a Medicare HMO and picks up traditional 
Medicare, this is in a way a continuation of a Medicare stay, because the 
government is paying the HMO for the coverage.   So you don't have to be 
within 30 days of the qualifying hospital stay at the time of the switch.  
On the same token, the days covered by the Medicare HMO count as part of the 
100 day benefit.

This is how it works, but I am not convinced your resident has a daily 
skilled need that entitles her to use Medicare.


From: "sheppard70057rn" <[EMAIL PROTECTED]>
Reply-To: [EMAIL PROTECTED]
To: <[EMAIL PROTECTED]>
Subject: HMO to PPS
Date: Mon, 2 Feb 2004 18:27:03 -0600
I have a question in regrds to HMO to PPS.

Had a resident admitted from hospital 12/30/03.  Attempted to get a skilled 
rate from HMO on this resident but they denied it.  However technically 
this resident would be at a SNF level, not an ICF level due to daily 
injections.  Then January 16, 2003 the HMO company gave us authorization 
for PT and OT to treat 3 x week.  They treated for two weeks and now it is 
time for reauthorization, however, we found out today that she disenrolled 
from HMO and now is Medicare Part a and b.  Can we pick her up for PPS now? 
 This resident's hospital stay was for COPD and exacerbation of CHF.  WE 
had been requesting therapy from the time she came to our building but the 
HMO drug their feet and did not give authorization for almost 2 1/2 weeks.

I called the FI, and they do not know.  The representative I talked to said 
she has to ask someone else and they will get back with me.  Does anyone 
out there know.
Dawn Sheppard, RN, CRNAC
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