(Medicare Benefit Policy Manual)

20.2.2.4 - Effect of Delay in Initiation of Deferred Care  (Rev. 1, 10- 01-03)  A3-3131.3.B.4, SNF -212.3.B.4  As indicated, where the required care commences within the anticipated time frame, the transfer requirement would be considered met even though more than 30 days have elapsed.  However, situations may occur where complications necessitate delayed initiation of the required care and treatment beyond the usual anticipated time frame (e.g., skilled rehabilitative services which will enable an amputee patient to use a prosthetic device must be deferred due to an infection in the stump).  In such situations, the 30-day transfer requirement may still be met even though care is not started within the usual anticipated time frame, if the care is begun as soon as medically possible and the care at that time is still reasonable and necessary for the treatment  of a condition for which the patient received inpatient hospital care.   20.2.2.5 - Effect on Spell of Illness  (Rev. 228, Issued: 10-13-16, Effective: 10-18-16, Implementation: 10-18-16)  In the infrequent situation where the patient has been discharged from the hospital to his or her home more than 60 days before he or she is ready to begin a course of deferred care in a SNF, a new spell of illness begins with the day the beneficiary enter s the SNF thereby generating another 100 days of extended care benefits (see Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, section 10.4.1).  Another qualifying hospital stay would not be required, providing the care furnished is clearly related to a hospital stay in the previous spell of illness and represents care for which the need was predicted at the time of discharge from such hospital stay.   20.2.3 - Readmission to a SNF (Rev. 242, Issued: 03-16-18, Effective: 06-19-18; Implementation: 06-19-18)  If an individual who is receiving covered post-hospital extended care, leaves a SNF and is readmitted to the same or any other participating SNF for further covered care within 30 days  after the day of discharge, the 30 -day transfer requirement is considered to be met.  The same is true if the beneficiary remains in the SNF to receive custodial care following a covered stay, and subsequently develops a renewed need for covered care there within 30 consecutive days after the first day of noncoverage.  Thus, the period of extended care services may be interrupted briefly and then resumed, if necessary, without hospitalization preceding the resumption of SNF coverage.  (See 20.2.2 and 20.2.2.3 above for situations where a period of more than 30 days between SNF discharge and readmission, or more than 30 days of noncovered care in a SNF, is followed by later covered care.)   20.3  Payment Bans (Rev. 1, 10-01-03)  A-01-131  20.3.1 - Payment Bans on New Admissions (Rev. 1, 10-01-03)  Under the Social Security Act at 1819(h)  and 1919(h)  and CMS regulations at 42 CFR 488.417, CMS may impose a denial of payment for new admissions (DPNA) against a SNF when CMS finds that a facility is not in substantial compliance with requirements of participation.  Further, the regulations require CMS to impose a DPNA when a SNF (1) fails to be in substantial compliance for three months after the last day of the survey identifying the noncompliance, or (2) is found to have provided substandard quality of care on the last three consecutive standard surveys.  A/B MACs (A) are responsible for applying these payment sanctions to new SNF admissions resulting from adverse survey findings.  The SNFs under a denial of payment sanction are still considered Medicare- participating providers.  Imposition of a payment ban on SNF new admissions is described in 42 CFR 488.401.  In applying payment bans, refer to the following definition of new admission to a SNF contained in 42 CFR 488.401.  [a] resident who is admitted to the facility on or after the effective date of a denial of payment remedy and, if previously admitted, has been discharged before that effective date.  Residents admitted before the effective date of the denial of payment, and taking temporary leave, are not considered new admissions, nor subject to the denial of payment.  Temporary leave is defined as residents who leave temporarily for any reason.  This definition would include both beneficiaries who are out of the SNF at midnight but who later return to the SNF and beneficiaries who require inpatient hospitalization and return to the SNF directly upon hospital discharge.  If residents were not subject to a denial of payment when they went on temporary leave, they are not, upon their return, considered new admissions for the purposes of the denial of payment.  A beneficiary is considered discharged when he/she leaves the facility with no expectation of return, e.g., a beneficiary transferred to another SNF or discharged to home, etc.  Beneficiaries admitted before the effective date of the denial of payment and taking temporary leave, whether to receive inpatient hospital care, outpatient services, or as therapeutic leave, are not considered new admissions, and are not subject to the denial of payment upon return.  This policy applies even if there are multiple hospitalizations and returns to the SNF during the period sanctions are in effect.  However, a resident who is discharged to a different SNF and is later readmitted to the original SNF, currently under a payment ban, will be subject to the denial of payment sanction.  Similarly, a beneficiary who is discharged from an acute care hospital to a long- term rehabilitation hospital, a wing bed, or a hospice would be considered a new admission upon return to the original SNF.   Beneficiaries enrolled through cost- based HMOs are subject to the same requirements as fee-for-service beneficiaries.   Hospices contract with SNFs for services related to the beneficiarys terminal condition.  These bills are not processed by the A/B MAC (A) or (HHH).  However, there will be situations where a beneficiary is admitted as a hospice patient, but later requires daily skilled care unrelated to the terminal condition.  If the beneficiary was initially admitted as a hospice patient prior to the date sanctions were imposed, and meets the requirements for Part A coverage; sanctions will not be applicable.  Benefits will be paid under SNF PPS from the first date the beneficiary qualifies for Medicare Part A for care unrelated to the terminal condition.  The facility must complete the Medicare -required assessments from the start of care for the unrelated condition.  20.3.1.1 - Beneficiary Notification  (Rev. 1, 10- 01-03)  Before admitting a beneficiary, the SNF must notify the beneficiary or responsible family member that sanctions have been imposed, and explain how the sanctions will affect the beneficiarys benefits.  This Notice of Non- Coverage also applies to former residents that had been discharged with no expectation of return and are being readmitted after the imposition of the payment ban.  SNFs failing to provide this notification will be held liable for all Part A services covered under SNF PPS.  The beneficiary n otice must meet the following criteria:   a. It must be in writing.   b. It must explain the reason sanctions were imposed.  c. It must explain the beneficiarys liability for the cost of SNF services during the period the payment ban is in effect.   d. It must explain that Medicare Part A benefits may be available if the beneficiary chooses a different Medicare -participating SNF that is not under sanction.   20.3.1.2 - Readmissions and Transfers  (Rev. 1, 10- 01-03)  When determining if the beneficiary was admitted prior to the imposition of the ban, the actual status of the beneficiary rather than the primary payor is the determining factor.  Therefore, there may be situations where the beneficiary is a private pay patient or a dual eligible who was receiving Medicaid benefits prior to the imposition of the payment ban.  If this private pay patient or dual eligible goes to the hospital for needed care, and meets the Medicare Part A criteria upon return to the SNF, the readmission is exempt from the denial of payment sanction.  20.3.1.3 - Sanctions Lifted:  Procedures for Beneficiaries Admitted During the Sanction Period  (Rev. 1, 10- 01-03)  For new admissions to certified beds, Medicare payments for eligible beneficiaries should begin on the date the sanction is lifted.  The beneficiary must meet technical eligibility requirements (e.g., a 3- day hospital stay, etc.), services must be reasonable and necessary and the beneficiary must be receiving skilled care.  The date the sanction is lifted is considered the first day of the Part A stay.  For SNF PPS payment purposes, the period between the actual date of admission and the last day the sanction was in effect should be billed as non-covered days.  20.3.1.4 - Payment Under Part B During a Payment Ban on New Admissions (Rev. 1, 10-01-03)  Facilities subject to a payment ban may continue to bill services for beneficiaries who are not in a Part A stay in the same way as any other SNF.  However, services that would have been payable to the SNF as Part A benefits in the absence of a payment san ction must not be billed to either the A/B MAC (A) or the A/B MAC (B) as Part B services.   20.3.1.5 - Impact of Consolidated Billing Requirements  (Rev. 1, 10-01-03)  The SNF may not charge the beneficiary or family members for any services that, in the absence of a payment sanction, would have been covered under the SNF PPS.  However, the beneficiary is entitled to reimbursement for those services excluded from the SNF PPS rate.  Services excluded from consolidated billing such as outpatient hospital emergency care and related ambulance service should be billed by the provider/supplier actually furnishing services, and not by the SNF.  20.3.1.6 - Impact on Spell of Illness  (Rev. 1, 10-01-03)  The SNF days during the sanction period will be used to track breaks in the spell of illness.  A beneficiarys care in an SNF met the skilled level of care standards if a Medicare SNF claim for the services provided in the SNF was denied on grounds other than that the services were not at a skilled level of care.  If the patient is receiving a skilled level of care the benefit period cannot end.  30 - Skilled Nursing Facility Level of Care - General  (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01 -07-14) A3-3132, SNF-214  Care in a SNF is covered if all of the following four factors are met:   The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel (see 30.2 - 30.4); are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services;   The patient requires these skilled services on a daily basis (see 30.6 ); and    As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (See 30.7.)   The services delivered are reasonable and necessary for the treatment of a patients illness or injury, i.e., are consistent with the nature and severity of the individuals illness or injury, the individuals particular medical needs, and accepted standar ds of medical practice.  The services must also be reasonable in terms of duration and quantity.  If any one of these four factors is not met, a stay in a SNF, even though it might include the delivery of some skilled services, is not covered.  For example, payment for a SNF level of care could not be made if a patient needs an intermittent rather than  daily skilled service.   In reviewing claims for SNF services to determine whether the level of care requirements are met, the A/B MAC (A)  first considers whether a patient needs skilled care.  If a need for a skilled service does not exist, then the daily and practical matter requirements are not addressed.  See section 30.2.2.1 for a discussion of the role of appropriate documentation in facilitating accurate coverage determinations for claims involving skilled care.  Additional material on documentation appears in the various clinical scenarios that are presented throughout these level of care guidelines.  Coverage of nursing care and/or therapy to perform a maintenance program does not turn on the presence or absence of an individuals potential for improvement from the nursing care and/or therapy, but rather on the beneficiarys need for skilled care.  Eligibility for SNF Medicare A coverage has not changed with the inception of PPS.  However, the skilled criteria and the medical review process have changed slightly.  For Medicare to render payment for skilled services provided to a beneficiary during a SNF Part A stay, the facility must complete an MDS.