BY PAUL BORJA, RN, MBA, DNP, EdD, PhD, PHN, CCM, ACM-RN, CMAC, CMCN, CNML, CMGT-BC, CDONA, FACDONA, FAACM, AND TERESA CAPINA, RN, MSN
Ever wondered if you or your loved ones qualify for skilled nursing facility (SNF) for rehabilitation or skilled nursing services? This article summarizes the requirements and important considerations.
The skilled nursing facility benefit is a means for payers to not just provide continuation of care, but also as a strategy to prevent readmissions to the acute care hospital. This benefit can be accessed in various ways depending on the payer type. Commercial insurance may allow this benefit to be accessed regardless of patient classification (inpatient vs observation) and length of hospitalization days. Medicare recipients (traditional fee-for-service), on the other hand, follow strict guidelines from CMS relative to the three-day qualifying inpatient stay requirement. In this article, we will focus on Medicare coverage.
Qualifying Inpatient Hospital Stay
According to Medicare.gov (n.d.), this means that you have at least three days in a row of inpatient hospital stay. Emphasis is on the consecutive days and the inpatient classification. This may be a concurrent inpatient hospital stay prior to discharge to a SNF or a prior stay in the acute care setting, excluding the day of discharge.
Next Generation ACO Model
CMS (n.d.). states that “the Next Generation ACO Model (NGACO) waiver allows an aligned beneficiary to be eligible for Medicare-covered SNF services when admitted to a SNF without a three-day qualifying inpatient stay, including beneficiaries who are in the hospital for fewer than three days or admitted directly from a physician’s office.”
Medicare Shared Savings Program (MSSP)
ACOs would also need to apply or participate in a two-sided model in the Shared Savings Program (levels C, D, or E of the basic track or the enhanced track). ACOs applying to or participating in a one-sided model (levels A or B) of the basic track are not eligible to apply for the SNF 3-Day Rule Waiver until the application cycle preceding their entry into a two-sided model, according to CMS (2024).
Code of Federal Regulations Title 42, § 425.612 (n.d.), ACO MSSP Beneficiaries must meet the following requirements:
- Not reside in a SNF or other long-term care setting.
- Be medically stable.
- It does not require inpatient or further inpatient hospital evaluation or treatment.
- Have certain and confirmed diagnoses.
- Have an identified skilled nursing or rehabilitation need that they cannot receive as an outpatient; and
- Have been evaluated and approved for admission to the SNF within three days prior to SNF admission by an ACO provider/supplier that is a physician, consistent with the ACO’s beneficiary evaluation and admission plan.
Your skilled nursing facility is covered by Medicare Part A including a semi-private room (with meals), skilled nursing care, rehabilitation services (physical, occupational, and speech therapies), medical social services, dietary counseling, medications, durable medical equipment, and supplies (used at the SNF and must not be confused as coverage at discharge), and ambulance transportation to the nearest provider of needed services, when other modes of transportation would endanger your health. Medicare Part A can cover up to 100 days in each benefit period. It pays the full costs of your first 20 days, and for days 21-100, Part A covers part of the cost, and you pay a daily coinsurance. However, the number of covered days is dependent on the medical necessity and frequency of skilled nursing services and rehabilitation services (if patient is participating in rehabilitation and is showing progress towards goals). Hence, case managers are to mention to the patient seeking SNF care of these requirements for continued SNF coverage. Anything beyond 100 days will be private pay. You would need to be out of a SNF or hospital for 60 days in a row, and three-day qualifying inpatient stay for Medicare beneficiaries to be eligible for a new benefit period (Medicare Interactive, n.d.).
Medicare-licensed skilled nursing facilities are paid on a Prospective Payment System (PPS), and the rates are adjusted for case mix and geographical variation to cover all costs. A Prospective Payment System is a method of reimbursement in which Medicare payment is made based on a pre-determined, fixed amount (CMS, n.d.).
CMS (n.d.) defined the elements for the PPS:
- Rates – addition of per diem federal rates and inclusion of “Part B add-on” and as of fiscal year 2022, utilized the Patient Driven Payment Model (PDPM). In PDPM, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10) codes are utilized for primary diagnosis and clinical categories.
- Transition – payment is based on the adjusted federal per diem rates.
- Case Mix Adjustment – under the Patient Driven Payment Model, the nursing groups are encompassed by Extensive Services, Special Care High, Special Care Low, and Clinically Complex nursing categories.
References
CMS (n.d.). Next Generation ACO Model. Retrieved from https://www.cms.gov/priorities/innovation/files/x/pioneeraco-snfwaiver.pdf.
CMS (n.d.). Prospective Payment Systems-General Information. Retrieved from https://www.cms.gov/medicare/payment/prospective-payment-systems.
CMS (n.d.). Skilled Nursing Facility PPS. Retrieved from https://www.cms.gov/medicare/payment/prospective-payment-systems/skilled-nursing-facility-snf.
CMS (2024). Medicare Shared Savings Program, Skilled Nursing Facility 3-Day Rule Waiver. Retrieved from https://www.cms.gov/files/document/snf-3-day-rule-waiver-guidance.pdf.
Code of Federal Regulations (n.d.). Waivers of payment rules or other Medicare requirements. Retrieved from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-425/subpart-G/section -425.612.
Medicare.gov (n.d.). Skilled Nursing Facility Care. Retrieved from https://www.medicare.gov/coverage/skilled-nursing-facility-care.
Medicare Interactive (n.d.). SNF costs and coverage. Retrieved from https://www.medicareintegrative.org/get-answers/medicare-covered-services/skilled-nursing facility-snf-services/snf-costs-and-coverage.
Paul Borja, RN, MBA, DNP, EdD, PhD, PHN, CCM, ACM-RN, CMAC, CMCN, CNML, CMGT-BC, CDONA, FACDONA, FAACM, is the director of care management for Adventist Health Lodi Memorial and Dameron Hospitals. He is an educator, leader, and a change-agent. He currently serves as the Sacramento Chapter President and our National Secretary. He is the board liaison for the Diversity, Equity, Inclusion and Belonging Committee, a Task Force member for the Rising Case Manager Committee, and an Editorial Board Member for CMSA Today. He is a Fellow of the American Academy of Case Management (FAACM) and Fellow of the Association of Certified Directors of Nursing Administration for Long-Term Care (FACDONA).
He is a lifelong learner, having completed terminal degrees such as doctor of nursing practice, doctor of education, and doctor of philosophy in organizational leadership. He is an avid believer of developing self as evidenced by his many professional certifications. He has vast experience in long-term care, acute rehab, managed care, home health, teaching, case management, and acute care. He has served as an item writer/developer and reviewer for the Certified Case Manager (CCM) examination since 2018. He was an advisory board member for the School of Administration and Management at California Coast University that later evolved into an adjunct professor role. He is open to mentoring others and creating opportunities for the many case managers who are leaders in their own right.
Teresa Capina, RN, MSN, is the continuity of care service director for Kaiser Permanente overseeing three medical centers. She has over 16 years of nursing, long-term care, leadership and case management experience. She obtained her master of science in nursing administration from the University of Phoenix and is currently working on her master of healthcare administration. She is highly involved with the CMSA Sacramento Chapter—recently as secretary and currently as a board director. She has been part of important quality improvement initiatives within and outside her organization. Teresa is a believer of lifelong learning, developing others, and contributing toward the progression of this chosen specialty of case management. On her spare time, she enjoys spending quality time with her two daughters in worthwhile activities such as baking and gardening; and she specifically value work-life balance by running and preparing for marathons.
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