(Medicare Benefit Policy Manual)

50.2 - Bed and Board in Semi -Private Accommodations Furnished in Connection With Nursing Care  (Rev. 1, 10- 01-03)  A3-3133.2, SNF -230.2   (See Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services, 10.1, for provisions relating to inpatient accommodations.)   50.3 - Physical Therapy, Speech -Language Pathology, and Occupational Therapy Furnished by the Skilled Nursing Facility or by Others Under Arrangements With the Facility and Under Its Supervision  (Rev. 242, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18)  Physical therapy (PT), speech -language pathology (SLP), and occupational therapy (OT) services must be provided by the SNF or by others under arrangements with the SNF for beneficiaries in either a covered Part A stay or a non -covered stay in the SNF (see Pub. 100-04, Medicare Claims Processing Manual, Chapter 6, 20.5, for a more detailed discussion of therapy services under consolidated billing, the SNF bundling requirement). Bundling of therapy services to the SNF is not required for beneficiaries residing in a non- certified portion of the same institution that also includes a participating distinct part SNF. See Chapter 7, SNF Part B Billing, 10 in the Medicare Claims Processing Manual, for a clarification of bill types used to make this distinction c lear in billing. For a discussion of skilled therapy (that is, PT, SLP, and OT) services in the context of the SNF level of care criteria, see 30.4ff. of this chapter.   50.4 - Medical Social Services to Meet the Patients Medically Related Social Needs  (Rev. 1, 10- 01-03)  A3-3133.4, SNF -230.4   Medical social services are those social services, which contribute meaningfully to the treatment of a patients condition.  Such services include, but are not limited to:   a. Assessment of the social and emotional factors related to the patients illness, his or her need for care, response to treatment, and adjustment to care in the facility;   b. Appropriate action to obtain case work services to assist in resolving problems in these areas; and   c. Assessment of the relationship of the patients medical and nursing requirements to his or her home situation, financial resources, and the community resources available to him or her in making the decision regarding their discharge.   50.5 - Drugs and Biologicals (Rev. 1, 10- 01-03)  A3-3133.5, SNF -230.5, Rev. A3- 1838 dated 06/01, A3- 3133.5.A, SNF -230.5.A, A3-3133.5.B, SNF -230.5.B, A3- 3133.5.C, SNF -230.5.C, A3- 3133.5.D, SNF -230.5.D   Drugs and biologicals for use in the facility, which are ordinarily furnished by the facility for the care and treatment of inpatients, are covered.  Such drugs and biologicals are not limited to those routinely stocked by the skilled nursing facility but include those obtained for the patient from an outside source, such as a pharmacy in the community.  Drugs and biologicals are included in the SNF PPS except for those Part B drugs specifically excluded.  Since the provision of drugs and biologicals is considered an essential part of skilled nursing care, a facility must assure their availability to inpatients in order to be found capable of furnishing the level of care required for participation in the program.  When a facility secures drugs and biological s from an outside source, their availability is assured only if the facility assumes financial responsibility for the necessary drugs and biologicals, i.e., the supplier looks to the facility, not the patient, for payment.  Payment may not be made for particular uses of drugs that the FDA has expressly disapproved or that are designated as not covered in the Medicare National Coverage Determinations Manual, chapter 2.   If the A/B MAC (A) has reason to question whether the FDA has approved a drug or biological for marketing, it will obtain satisfactory evidence of FDAs approval.  Acceptable evidence includes a copy of the FDAs letter to the drugs manufacturer approving the new drug application (NDA); or listing of the drug or biological in the FDAs Approved Drug Products or FDA Drug and Device Product Approvals; or a copy of the manufacturers package insert, approved by the FDA as part of the labeling of the drug, containing its recommended uses and dosage, as well as possible adverse reactions and recommended precautions in using it.  When necessary, the Medicare regional office may be able to help in obtaining information.  See instruction in the Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services, 30.1, Drugs Included in the Drug Compendia, which also apply to drugs furnished to SNF inpatients.  However, drugs not included, or approved for inclusion, in the drug compendia are nevertheless covered in a SNF if such drug:   1. Was furnished the patient during their prior hospitalization;   2. Was approved for use in the hospital by the hospitals pharmacy and drug therapeutics (or equivalent) committee;  3. Is required for the continuing treatment of the patient in the skilled nursing facility; and   4. Is reasonable and necessary.   Under the limited circumstances mentioned in items 1 through 4 above, a combination drug approved by a hospital pharmacy and drug therapeutics committee may also be covered as an extended care service.   Rules for drugs and biologicals applicable to hospital inpatients found in the Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services, 30, 30.3, and 30.5, also apply to inpatients of SNFs. They are:    General information concerning drugs and biologicals furnished to inpatients;    Combination drugs; and   Drugs for use outside the SNF.  50.6 - Supplies, Appliances, and Equipment  (Rev. 1, 10- 01-03)  A3-3133.6, SNF -230.7   Instructions in the Medicare Benefit Policy Manual, Chapter 1, Hospital Inpatient Services, 40 - Supplies, Appliances, and Equipment, also apply to SNF inpatients.  50.7 - Medical Service of an Intern or Resident -in-Training  (Rev. 228, Issued: 10-13-16, Effective: 10-18-16, Implementation: 10-18-16)  The medical services of an intern or resident- in-training under an approved teaching program of a hospital with which the facility has in effect the required transfer agreement are covered under hospital insurance (see Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, chapter 5, section 30.2 for a discussion of the SNFs required transfer agreement with a hospital).  An approved teaching program means a program approved by the Council on Medical Education of the American Medical Association or, in the case of an osteopathic hospital, approved by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association.  In the case of services of an intern or resident -in-training in the field of dentistry in a hospital or osteopathic hospital, the teaching program must have the approval of the Council on Dental Education of the America n Dental Association.  The medical and surgical services furnished to the facilitys patients by interns and residents -in-training of a hospital with which the facility has a transfer agreement are covered under medical insurance if the services are not covered under hospital insurance.   50.8 - Other Services  (Rev. 1, 10-01-03)  A3-3133.9, SNF-230.10  50.8.1 - General  (Rev. 1, 10-01-03)  A3-3133.9.A, SNF-230.10.A  Other services that are necessary to the health of the patients are covered if the services are generally provided by, or under arrangements made by, skilled nursing facilities.  The medical and other health services described in the Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, 10 - 10.2.4, are generally provided by, or under arrangements made by, skilled nursing facilities and are therefore extended care services.  For coverage of diagnostic services and radiologic al therapy under Part A, the conditions described in 70.1 must be met.   Items or services that would not be included as inpatient hospital services if furnished to an inpatient of a hospital are also excluded from coverage as extended care services.  For instance, the provision of personal laundry services by skilled nursing f acilities is not a covered service under Medicare, since it would not be covered if provided to an inpatient of an acute care hospital.  See the Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, 10, for covered inpatient hospital services.  The use of an operating room and any special equipment, supplies, or services would not constitute covered extended care services except when furnished to the facility by a hospital with which the facility has a transfer agreement, since operating rooms ar e not generally maintained by skilled nursing facilities.  However, supplies and nursing services connected with minor surgery performed in a skilled nursing facility that does not require the use of an operating room or any special equipment or supplies a ssociated with such a room would be covered extended care services and paid as part of inpatient SNF PPS.   50.8.2 - Respiratory Therapy  (Rev. 242, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18)  Prior to BBA 1997, respiratory therapy could be provided by a SNF either under an arrangement with a hospital with which the SNF had a transfer agreement or through the SNFs nursing staff.  Section 4432(b)(5)(D) of the BBA amended section 1861(h)(7)  of the Act to cover the full range of services that SNFs generally provide, either directly or under arrangements with any qualified outside source.  As a result, the services of respiratory therapists are now covered under Part A when provided under arra ngements made directly between the SNF and any qualified respiratory therapist, regardless of whether the therapist is employed by the SNFs transfer agreement hospital (see the regulations at 42 CFR 409.27(b)).   60 - Covered Extended Care Days  (Rev. 1, 10- 01-03)  Not Applicable   See the Medicare Benefit Policy Manual, Chapter 3, Duration of Covered Inpatient Services, for the following topics:    Post-hospital extended care benefit days available in a benefit period;    Definition of an inpatient benefit day;    Late discharge;    Leave of absence;    Discharge or death on first day of entitlement or participation; and    Inpatient service days counting toward benefit maximums.   70 - Medical and Other Health Services Furnished to SNF Patients  (Rev. 228, Issued: 10 -13-16, Effective: 10 -18-16, Implementation: 10- 18-16)  The medical and other health services listed below are covered under Part B when furnished by a participating SNF either directly or under arrangements to inpatients who are not entitled to have payment made under Part A (e.g., benefits exhausted or 3- day prior -stay requirement not met).   Services payable under Part B are:    Diagnostic x- ray tests, diagnostic laboratory tests, and other diagnostic tests;    X-ray, radium, and radioactive isotope therapy, including materials and services of technicians;    Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations;    Prosthetic devices (other than dental) which replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of  such devices;    Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes including adjustments, repairs, and replacements required because of breakage, wear, loss, or a change in the patients physical condition;    Outpatient physical therapy, outpatient speech language pathology services, and outpatient occupational therapy (see Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 10, Covered Medical and Other Health Services, 220.1.4);    Screening mammography services;    Screening pap smears and pelvic exams;    Influenza, pneumococcal pneumonia, and hepatitis B vaccines;    Some colorectal screening;    Prostate screening;    Ambulance services;    Hemophilia clotting factors.