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The guidelines for Medicare are lengthy and complex. Yet, understanding the inner workings of the Medicare program is necessary for providers to guide patients and their families through the maze of long term/post-acute care coverage. With any program, especially one that has been in existence for more than 50 years, it’s common for myths to develop over time.

 

Below are eight Medicare myths and truths to keep in mind while navigating coverage for long term care skilled services.

 

Myth #1: A resident with psychosis will not qualify for Medicare Part A skilled services.

Although most psychiatric services will not qualify as Medicare Part A skilled services, there are some instances when a resident will qualify when coming straight from the hospital, at least for a short period of time.

To help determine whether a resident qualifies, first determine if the stay in the psychiatric hospital meets the three-day qualifying hospital requirement. If it does, the next area to review is whether the care meets the requirements for skilled services under Medicare Part A.

The resident may need to have his or her medications adjusted; there is always the potential for an adverse drug reaction if any medications were changed or added. In addition, depending on the time spent in the hospital, there may have been some deterioration and the resident may receive physical therapy orders upon discharge from the hospital. Other areas to review include hearing, speech and vision, cognitive patterns, mood, behavior, functional status, and medications.

 

Myth #2: A resident may be covered for the first five days to observe and assess his or her condition.

The Centers for Medicare & Medicaid Services (CMS) does not specify a minimum or maximum time covered; however, administrative presumption of coverage may be an option.

Remember, though, that the use of the administrative presumption is reserved only for residents being directly admitted from a three-day qualifying hospital stay. In addition, this administrative presumption only covers up to and including the assessment reference date (ARD) if no skilled need is identified on the initial admission/readmission minimum data set (MDS). The regulation indicates that a resident can be in skilled care “until the condition of the patient is stabilized.” Typically, skilled care for observation and assessment lasts for a few weeks or less.

 

Myth #3: A new diagnosis triggers a new benefit period.

This is one of the most dangerous Medicare myths out there. It can impact not only resident care, but also customer service and can have a significant financial impact as well. The only way a resident can earn a new 100-day benefit period under skilled nursing facility (SNF) Medicare Part A is to complete a 60-day period of wellness. The calculation for earning a new benefit period is based on two criteria: determining when skilled services ended and counting days.

 

Myth #4: All residents who are receiving tube feeding are always skilled and always will be skilled.

The caveat lies with the level of calories and fluid the resident is receiving via the tube. Residents who get 26 to 50 percent of their calories and 501 CCs of fluid per day via the feeding tube, or residents who receive 51 percent or more of their calories via the feeding tube, will automatically qualify for Medicare Part A benefits in a SNF. They are required to continue on Medicare to use a full 100-day benefit period until they drop below such levels on an MDS.

These levels will also continue to count as part of that spell of illness and prevent the resident from attaining the 60-day period of wellness to qualify for a new 100-day benefit period.

Residents who meet the caloric and fluid requirements will remain at a skilled level of care for a full 100 days, as long as they remain at those required levels. In addition, the resident will not qualify for a new 100-day benefit period unless he or she drops below the calorie and fluid levels previously identified for 60 consecutive days without any other skilled service in the SNF inpatient hospital stay or remains at those calorie and fluid levels identified previously but discharges to home with skilled services being provided in the home for 60 consecutive days.

 

Myth #5: As long as there is an inpatient hospital stay or Medicare Part A SNF stay within the last 30 days, the SNF can pick the resident back up on Medicare Part A.

Although this is partly true, the most important criterion using the 30-day transfer window is relating the reason for coverage back to the original hospitalization or a condition that arose during treatment. If the reason to pick the resident back up under Medicare Part A is completely unrelated to the original hospitalization or subsequent SNF stay, the criteria outlined in the regulation regarding the 30-day transfer rules are not met, and the resident should not be put back on Medicare Part A.

 

Myth #6: A resident on Medicare Part A in a SNF can never leave the SNF for an overnight leave of absence.

Often, a resident is unable to leave the SNF due to the complexity of the services being rendered. When considering an overnight leave of absence (LOA), consider the following: Can the resident safely be away from the SNF, and can the family or responsible party be taught to safely meet the resident’s needs while out of the SNF? Are the absences infrequent in nature and not for prolonged periods of time?

Consult with the resident’s physician to notify him or her of the LOA request and get some feedback from the physician’s point of view on whether the LOA is feasible.

For example, if a resident is able to leave the SNF on a weekly basis for an overnight visit, or if the resident leaves for prolonged periods of time three times per week to attend an off-site bingo game, it is doubtful that the practical matter criteria is being met. Remember, one of the four criteria related to meeting the skilled services requirement in a SNF is the practical matter criterion identified in Section 30.7 of the Medicare Benefit Policy Manual (Pub. 100-02).

Myth #7: You never have to issue more than one notice regarding a Medicare stay at the same time.

If only that were a true statement. There are so many notices that it can be confusing to try to understand which notice is issued under what circumstances. To further complicate things, there are times when more than one notice will be issued at relatively the same time. Review Chapter 30, Section 261 of the Medicare Claims Processing Manual for instances when more than one notice may be required.

 

Myth #8: There is never an instance where no notice is required at the end of Medicare coverage.

When a beneficiary exhausts his or her 100-day benefit period in the SNF, there is no notice required. The Beneficiary Notification Initiative (BNI) process allows beneficiaries to be notified and gives them the ability to appeal decisions being made by providers in relation to their Medicare coverage.

The end of the 100-day SNF benefit period is not a provider decision, but rather a statutory end of coverage based on the Medicare guidelines, and there is nothing that the beneficiary can challenge or appeal. While no formal notice or form is required, it is recommended the beneficiary be informed about the end of the 100-day benefit period.

Long term care providers need a thorough understanding of Medicare’s guidelines so they can best serve their residents. Visit CMS.gov for the latest changes. And, keep in mind the eight Medicare myths. Doing so may save time and prevent missteps.