Medicare stands as a cornerstone of health care provision in the United States, offering vital coverage to millions of individuals age 65 and older, as well as those living with certain qualifying conditions and disabilities. However, the landscape of Medicare coverage is intricate, and health care workers must navigate a myriad of requirements and regulations.

Ongoing staffing turnover may have created a knowledge gap for some skilled nursing facility (SNF) staff with regard to the requirements for SNF Medicare Part A coverage. For example, when a key staff member, entrusted with crucial Medicare coverage responsibilities, either leaves the SNF or takes on other work, the staff may be left without vital guidance. This article describes the essential requirements of the Medicare SNF stay and the resources needed to avoid inadvertent noncompliance during staffing changes.

Medicare Compliance and Consequences

Failure to adhere to Medicare regulations can result in the inability to bill Medicare, leaving the SNF solely responsible for covering the cost of services provided, also known as provider liability. Moreover, instances of fraud or abuse related to the Medicare Part A program can lead to criminal, civil, and administrative repercussions for the individuals and SNFs involved. 

Due to the high risks associated with Medicare compliance, knowledge of how the program works should be shared with more than one SNF staff member. It is incumbent on key staff members, such as the nurse assessment coordinator, Medicare case manager, or director of nursing services, to possess a firm understanding of Medicare rules, thus ensuring compliance and upholding the integrity of the program, especially in times of staffing flux.
Medicare regulations are outlined in regulatory manuals found on the Internet-Only Manual section of the Centers for Medicare & Medicaid Services (CMS) website. Staff less familiar with Medicare Part A SNF coverage requirements should consult the available resources, especially chapter 8 of the Medicare Benefit Policy Manual (MBPM)¹ and chapters 6 and 30 of the Medicare Claims Processing Manual (MCPM),² among others.

Technical Requirements

Eligibility for Medicare Part A coverage in a SNF has many requirements: enrollment and entitlement to Medicare Part A benefits, completion of a 3-day qualifying hospital stay (QHS), availability of SNF benefit days, and physician certification of the need for a skilled level of medical care. Understanding these requirements will help ensure that individuals receive their entitled coverage under the program and the SNF receives accurate reimbursement.

Qualifying Hospital Stay

To meet the QHS requirement for Medicare Part A coverage in a SNF, a beneficiary must have been admitted as an inpatient for a minimum of three consecutive midnights and released to a Medicare-certified SNF bed within 30 days of discharge from the QHS. The stay doesn’t have to occur in the same hospital, but the hospitalization must be deemed medically necessary for individuals to receive essential treatment and services. This requirement extends to stays in psychiatric hospitals and foreign hospitals. However, time spent in the emergency department, observation units, or outpatient settings does not contribute to meeting the QHS criterion.

Medicare Part A Benefit Period

Once a QHS is achieved, the beneficiary must have days available in their 100-day benefit period to use during a SNF stay. SNF staff must verify the benefit period before assigning Medicare Part A as a payer for a new admission. They should check the online Medicare verification system3 and interview the beneficiary to confirm the days available. Because the online verification system is updated solely on Medicare claims, if a claim from a previous SNF was not submitted, then the interview with the beneficiary, or their representative, becomes essential to determine past SNF stays and the number of benefit days remaining.

Physician Certifications

Once the beneficiary is admitted to the SNF, the physician must certify and recertify the SNF stay at set intervals. Medicare may not be billed for a SNF stay unless the initial certification and recertifications are in place. Chapter 8 of the MBPM has additional information on the technical requirements of an extended care stay.

Skilled Level of Care Requirements for Extended Care Coverage

Not only do beneficiaries have to meet the technical requirements for Medicare Part A, but they must also require daily skilled care to be covered throughout the SNF stay. Skilled nursing coverage is composed of both direct skilled nursing services, such as intravenous medications or tube feeding, and indirect nursing services, such as management of the plan of care, observation and assessment, and teaching and training. Skilled rehabilitation encompasses physical therapy, occupational therapy, and speech language pathology.

Several criteria must be met to qualify for a skilled level of care, also known as inpatient care, in a SNF:

• The skilled services must be ordered by a physician for a condition for which the resident was treated in the QHS or that arose in the SNF during the skilled stay.
• Skilled services must be delivered daily (i.e., seven days a week for nursing and five days a week for rehabilitation).
• The care delivered must be reasonable and necessary and can only be provided as an inpatient in a SNF.
• Daily documentation must support the ongoing need for clinical skilled care for the beneficiary to continue the Medicare stay in the SNF.

In only one instance is daily documentation not required: the Administrative Presumption of Coverage. This presumption, based on correct assignment into designated case-mix classifiers, allows Medicare Part
A coverage through the Assessment Reference Date of a Medicare 5-Day Prospective Payment System assessment for a resident admitted directly from a QHS. More on skilled coverage and the administrative presumption can be found in chapter 8 of the MBPM.

Ending a SNF Stay

Once a resident no longer meets the daily skilled care coverage requirements for Medicare Part A, the SNF staff must notify the resident in writing of this change of status, as well as their appeal rights, in a timely fashion.4 Residents and/or their responsible parties who disagree with this decision have two avenues for appeal: the expedited appeal process and the standard appeal process. Failure to notify the resident of his or her potential financial liability and appeal rights may result in provider liability. Chapter 30 of the MCPM has more information on the notification process.

Conclusion

Nursing home providers play a vital role in caring for Medicare beneficiaries and maintaining compliance with the Medicare program during a SNF stay. However, navigating the complexities of Medicare Part A SNF coverage requires a thorough understanding of its requirements. By mastering the intricacies of coverage requirements and the resources outlined in this article, SNF staff can confidently manage Medicare Part A SNF stays, ensuring the delivery of optimal care to beneficiaries while maintaining program integrity even amid staff vacancies. 

References
1. Centers for Medicare & Medicaid Services. (2021a). Medicare Benefit Policy Manual (chap. 8, Rev. 10880, 08-06-21). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.html
2. Centers for Medicare & Medicaid Services. (2021b). Medicare Claims Processing Manual (chap. 6, Rev. 10880, 08-06-21; chap. 30, Rev. 12423, 12-20-23). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html
3. Centers for Medicare & Medicaid Services. (2024). HIPAA Eligibility Transaction System (HETS). https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/
4. Centers for Medicare & Medicaid Services. (2023). Beneficiary Notices Initiative (BNI). https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative​

Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC,  is a curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN).