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Section 1 Introduction
- Introduction
- Federal Government Administration
- Fundamentals of Medicare: State Responsibilities
- Fundamentals of Medicare: Participating Providers
- Voluntary and Involuntary Termination of Provider Agreement
- Disclosure of Health Insurance Information
- Privacy Act
- National Provider Identifier
- Legacy Provider Numbers/Provider Transaction Access Numbers (PTANs)
- Medicare Administrative Contractors
- Fundamentals of Medicare: Information References
- Acronyms
- Fundamentals of Medicare: Glossary of Terms
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Section 2 Medicare Basics
- The History of Medicare
- What Is the Medicare Program and How Is It Funded?
- Medicare Eligibility and Premiums
- The Social Security Administration and Medicare Enrollment
- The Medicare Card
- Medicare Part A
- Inpatient Hospital Care
- Skilled Nursing Facility Inpatient Care
- Home Health Care Benefit
- The Hospice Benefit
- Medicare Part B Medical Insurance
- Fundamentals of Medicare - Medicare Program Exclusions
- Medicare Advantage Organizations
- Medicare Secondary Payer
- Supplemental Insurance
- Coordination of Benefits Trading Partners
- Section 3 Fraud and Abuse
- Section 4 Getting Ready to Bill Medicare
Section 2: Medicare Basics
Skilled Nursing Facility Inpatient Care
Table of Contents
- Skilled Nursing Facility Inpatient Care
- Requirements for Coverage
- Inpatient SNF/Swing Bed Benefit Days and Costs
- Skilled Nursing Facility Services
- Swing Bed Facilities
Skilled Nursing Facility Inpatient Care
The SNF inpatient benefit is for those beneficiaries who need skilled nursing or rehabilitative care following an inpatient hospital stay. A SNF can be a freestanding facility or part of a hospital (known as a swing-bed hospital). Hospitals having a swing-bed unit follow the same regulations as a freestanding SNF.
Requirements for Coverage
In order for Medicare to consider payment of a SNF inpatient stay, there are technical and medical requirements a patient must meet. The beneficiary must meet all of the following requirements.
Technical Requirements
- The beneficiary is enrolled in Medicare Part A
- The beneficiary receives services in a Medicare-certified SNF
- The beneficiary has SNF days remaining in his/her benefit period
- The beneficiary has had a “three-day qualifying hospital stay”
- Stays totaling three consecutive days in one or more hospitals can meet the three-consecutive-calendar-day requirement. In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital day.
- The hospital discharge must have occurred on or after the first day of the month in which the patient becomes entitled to Medicare Part A.
- The three-day hospital stay need not be in a hospital with which the SNF has a transfer agreement. However, the hospital must be either a participating general, psychiatric, or tuberculosis hospital or an institution that at least meets the conditions of participation for hospitals.
- Stays in Christian Science Sanatoriums are excluded for the purpose of satisfying the three-day period of hospitalization.
- If a SNF inpatient drops to a noncovered LOC but then rises to a Medicare-covered LOC within 30 days, the patient does not need a new three-day qualifying hospital stay.
- For more information on the hospital requirements for a valid qualifying hospital stay, refer to the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 8 Manual, Section 20.1.
- The beneficiary meets the “30-day transfer” rule.
- The patient must be admitted to the SNF within 30 days of discharge from their three-day qualifying hospital stay.
- The 30-day rule also applies when a patient is discharged from a SNF and is then admitted into a different SNF or readmitted into the same SNF.
- An exception to the 30-day transfer rule can be applied for certain conditions where SNF care is a necessary and proper continuation of treatment initiated during the hospital stay, but it would be inappropriate from a medical standpoint to begin such treatment within 30 days after hospital discharge. This exception can only be applied where, under accepted medical practice, the established pattern of treatment for a particular condition indicates that a covered level of SNF care will be required within a predetermined time frame. Accordingly, to qualify for this exception, it must be medically predictable at the time of hospital discharge that a covered level of skilled nursing facility care will be required within a predictable period of time for the treatment of a condition for which hospital care was received. In addition, the patient must begin receiving such care within that time frame.
- For more information regarding the 30-day transfer rule, refer to the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 20.2.
Medical Requirements
The beneficiary needs daily skilled care or rehabilitation services as ordered by a physician. These skilled services can only be rendered by, or under the direct supervision of, skilled nursing or rehabilitation staff. In addition, the skilled services the patient receives must be for a medical condition they were treated for during the three-day qualifying hospital stay, or for a condition that arose during that hospital stay or while the patient was receiving Medicare-covered SNF care.
The requirement of “daily” skilled services should not be taken so literally that occasional sessions missed due to holidays or illness will make the patient not meet the daily requirement for skilled services.
For more information regarding CMS’ definition of “daily” skilled services, refer to the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30.6.
Inpatient SNF/Swing Bed Benefit Days and Costs
When all the above requirements for coverage are met, a beneficiary can receive up to 100 days of care in a SNF/swing bed, and Medicare will pay part or all of the services rendered. Out of these 100 days, the first 20 days are considered full days and the beneficiary is not charged any cost-sharing amount. The remaining 80 days are coinsurance days, where Medicare pays for the medically necessary days with the exception of the beneficiary’s coinsurance responsibility.
Once a beneficiary has used their 100 SNF benefit days, Medicare can no longer make payment under Medicare Part A. This is known as “benefits exhausted.” When benefits are exhausted under Part A, some services that a beneficiary receives can be covered under Part B. In addition, all 100 SNF benefit days are renewable with a new benefit period. Remember, if a beneficiary is not “facility-free” or at a noncovered level of care for more than 60 days in a row, a beneficiary is not entitled to a new benefit period. A beneficiary should not be considered at a non-skilled level of care just because they have exhausted their benefits. A benefit period can continue for years if the patient continues to be an inpatient and is still receiving skilled services.
A patient cannot use their hospital LTR days in a SNF. SNF days are separate from the inpatient hospital set of days but are connected to the same benefit period. For more information, refer to the benefit period section earlier in this training guide.
Did You Know? The formula that calculates the hospital cost-sharing amounts also works for SNF coinsurance. The SNF coinsurance amount is always the inpatient hospital deductible divided by eight, or half of the hospital coinsurance, or the lifetime reserve amount divided by four.
Medicare Deductible, Coinsurance and Premium Rates
MLN Matters® MM13365: Medicare Deductible, Coinsurance, & Premium Rates: CY
2024 Update
Skilled Nursing Facility Services
When a patient meets all the requirements for coverage, Medicare pays for room and board and ancillary services needed to treat the patient’s condition.
Covered Services
Covered inpatient SNF services include, but are not limited to:
- Semiprivate room
- All meals including special diets
- Skilled nursing care
- Drugs/medications
- Rehabilitation services
- Speech, physical and occupational therapy
Noncovered Services
Noncovered inpatient hospital services include, but are not limited to:
- Custodial care
- Private duty nurses
- Personal convenience items such as television or telephone
Private Rooms
Under the inpatient SNF benefit, Medicare Part A will pay for a semiprivate room. Private rooms can be covered under Medicare when it is medically necessary that the patient have a private room. In addition, a private room can be paid for when the SNF has no semiprivate rooms available.
When a private room is requested by the patient or is not medically necessary, Medicare will pay the semiprivate room rate. The beneficiary is responsible for the difference between the private and semiprivate room rates.
Reimbursement System
Since 1998, SNFs are reimbursed under the SNF prospective payment system (PPS). Beginning in 2002, swing bed facilities are reimbursed under the swing bed PPS. Reimbursement under SNF and swing bed PPS is based on the RUG-III category of the patient. CAH swing bed reimbursement is paid at cost.
Swing Bed Facilities
The assignment of swing bed status to hospitals occurs when rural areas are lacking SNFs to care for patients who require extended skilled care following a hospital stay. If there is a lack of SNF beds in the immediate area, rural hospitals that have fewer than 100 beds can apply to be certified as a “swing bed” hospital.
In the event that the hospital patient no longer requires acute care, and there is no available bed in a SNF in which to transfer the patient, the certified “swing bed” hospital can reassign that patient to the SNF benefit. The hospital discharges (transfers) the beneficiary as if he/she were actually leaving the hospital. Subsequent claims are then submitted to the Intermediary using the swing bed provider number.
The benefit days used in a “swing bed” are taken from the SNF benefit. All coverage determinations are made based on the required skilled care criteria applied to SNFs.
CAH swing bed facilities are not subject to the SNF PPS regulations, for example the MDS does not have to be done for a beneficiary in a CAH swing bed. The SNF regulations regarding the three-day stay and thirty-day transfer, along with the other SNF regulations do apply.
Revised 5/31/2024