evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
20.1.1 - Three -Day Prior Hospitalization - Foreign Hospital  (Rev. 261, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)  Regardless of whether a foreign hospital stay is itself coverable under the heading of foreign hospital services (see Pub. 100- 04, Medicare Claims Processing Manual, chapter 32, 350ff. for a description of the foreign hospital services that are payable by Medicare), an inpatient stay of 3 or more days in a hospital outside the United States may nevertheless satisfy the prior inpatient stay requirement for post -hospital extended care services within the United States as long as the foreign hospital can qualify as an emergency hospital (see Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, c hapter 5, 20.2, for the definition of an emergency services hospital).  If a stay of 3 or more days in a hospital outside the United States is being considered to satisfy the prior inpatient stay requirement, the SNF will submit documentation to the A/B M AC (A).  This evidence will be either:   A.  An itemized bill or hospital form prepared by the foreign hospital showing dates of admission and discharge and a description of the illness or injury treated (obtained from the beneficiary); or   B.  A medical report prepared by the foreign hospital and sent to the patients U.S. physician showing dates of admission and discharge and a description of the illness or injury treated (obtained from the physician).  If neither type of evidence can be obtained, the SNF will secure whatever information is available for submission to the A/B MAC (A).  When the A/B MAC (A) receives a bill involving a prior inpatient stay in a foreign hospital, it contacts the regional off ice for a determination as to whether the prior stay requirement is met.  If the regional office states the hospital does not qualify as an emergency hospital, the A/B MAC (A) advises the provider that the prior inpatient stay requirement is not met.  If the regional office states the hospital qualifies as an emergency hospital and documentation is submitted as outlined in either 20.2.1 or 20.2.2 which otherwise meets the prior -stay requirement, the A/B MAC (A) processes the SNF claim.
(Medicare Benefit Policy Manual)
20.2 - Thirty -Day Transfer  (Rev. 1, 10- 01-03)  A3-3131.3, SNF -212.3   20.2.1 - General  (Rev. 161, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13)  A3-3131.3.A, SNF-212.3.A  Post-hospital extended care services represent an extension of care for a condition for which the individual received inpatient hospital services.  Extended care services are post-hospital if initiated within 30 days after discharge from a hospital stay that included at least three consecutive days of medically necessary inpatient hospital services.  In certain circumstances the 30 -day period may be extended, as described in 20.2.2 below.  Even if a beneficiarys care during a qualifying hospital stay becomes less intensive during the latter part of the stay, the date of hospital discharge in this context is still considered to be the day that the beneficiary physically leaves the hospi tal, and the level of care being furnished at that particular point is not a determining factor as long as some portion of the stay included at least 3 consecutive days of medically necessary inpatient hospital services.
(Medicare Benefit Policy Manual)
In determining the 30-day transfer period, the day of discharge from the hospital is not counted in the 30 days.  For example, a patient discharged from a hospital on August 1 and admitted to a SNF on August 31 was admitted within 30 days.  The 30-day period begins on the day following actual discharge from the hospital and continues until the individual is admitted to a participating SNF, and requires and receives a covered level of care.  Thus, an individual who is admitted to a SNF within 30 days after discharge from a hospital, but does not require a covered level of care until more than 30 days after such discharge, does not meet the 30-day requirement. (See 20.2.2 below for an exception under which such services may be covered.)  Conversely, as long a s a covered level of care is  needed and initiated in the SNF within the specified timeframe, the timely transfer requirement is considered to be met even if actual Medicare payment  does not commence until later (for example, in a situation where another payment source that is primary to Medicare has assumed financial responsibility for the initial portion of the SNF stay).   If an individual whose SNF stay was covered upon admission is thereafter determined not to require a covered level of care for a period of more than 30 days, payment could not be resumed for any extended care services he or she may subsequently require, even though he or she has remained in the facility, until the occurrence of a new qualifying hospital stay.  In the absence of a new qualifying hospital stay, such services could not be deemed to be post-hospital extended care services. (For exception, see 20.2.2 below.)  20.2.2 - Medical Appropriateness Exception  (Rev. 1, 10-01-03)  A3-3131.3.B, SNF-212.3.B
(Medicare Benefit Policy Manual)
An elapsed period of more than 30 days is permitted for SNF admissions where the patients condition makes it medically inappropriate to begin an active course of treatment in a SNF immediately after hospital discharge, and it is medically predictable at the time of the hospital discharge that he or she will require covered care within a predeterminable time period.  The fact that a patient enters a SNF immediately upon discharge from a hospital, for either covered or noncovered care, does not necessarily negate coverage at a later date, assuming the subsequent covered care was medically predictable.   20.2.2.1 - Medical Needs Are Predictable  (Rev. 1, 10- 01-03)  A3-3131.3.B.1, SNF -212.3.B.1  In determining the type of case that this exception is designed to address, it is necessary to recognize the intent of the extended care benefit.  The extended care benefit covers relatively short -term care when a patient requires skilled nursing or skilled rehabilitation services as a continuation of treatment begun in the hospital.  The requirement that covered extended care services be p rovided in a SNF within 30 days after hospital discharge is one of the means of assuring that the SNF care is related to the prior hospital care.   This exception to the 30- day requirement recognizes that for certain conditions, SNF care can serve as a necessary and proper continuation of treatment initiated during the hospital stay, although it would be inappropriate from a medical standpoint to begi n such treatment within 30 days after hospital discharge.  Since the exception is intended to apply only where the SNF care constitutes a continuation of care provided in the hospital, it is applicable only where, under accepted medical practice, the estab lished pattern of treatment for a particular condition indicates that a covered level of SNF care will be required within a predeterminable time frame.  Accordingly, to qualify for this exception it must be medically predictable at the time of hospital dis charge that a covered level of SNF care will be required within a predictable period of time for the treatment of a condition for which hospital care was received and the patient must begin receiving such care within that time frame.
(Medicare Benefit Policy Manual)
An example of the type of care for which this provision was designed is care for a person with a hip fracture.  Under the established pattern of treatment of hip fractures it is known that skilled therapy services will be required subsequent to hospital ca re, and that they can normally begin within four to six weeks after hospital discharge, when weight bearing can be tolerated.  Under the exception to the 30- day rule, the admission of a patient with a hip fracture to a SNF within 4 to 6 weeks after hospita l discharge for skilled care, which as a practical matter can only be provided on an inpatient basis by a SNF, would be considered a timely admission.  20.2.2.2 - Medical Needs Are Not Predictable  (Rev. 1, 10- 01-03)  A3-3131.3.B.2, SNF -212.3.B.2
(Medicare Benefit Policy Manual)
When a patients medical needs and the course of treatment are not predictable at the time of hospital discharge because the exact pattern of care required and the time frame in which it will be required is dependent on the developing nature of the patient s condition, an admission to a SNF more than 30 days after discharge from the hospital is not justified under this exception to the 30- day rule.  For example, in some situations the prognosis for a patient diagnosed as having cancer is such that it can re asonably be expected that additional care will be required at some time in the future.  However, at the time of discharge from the hospital it is difficult to predict the actual services that will be required, or the time frame in which the care will be ne eded.  Similarly, it is not known in what setting any future necessary services will be required; i.e., whether the patient will require the life -supporting services found only in the hospital setting, the type of care covered in a SNF, the intermittent ty pe of care which can be provided by a home health agency, or custodial care which may be provided either in a nursing home or the patients place of residence.  In some instances such patients may require care immediately and continuously; others may not r equire any skilled care for much longer periods, perhaps measured in years.  Therefore, since in such cases it is not medically predictable at the time of the hospital discharge that the individual will require covered SNF care within a predeterminable time frame, such cases do not fall within the 30- day exception.  20.2.2.3 - SNF Stay Prior to Beginning of Deferred Covered Treatment  (Rev. 1, 10- 01-03)  A3-3131.3.B.3, SNF -212.3.B.3
(Medicare Benefit Policy Manual)
A3-3131.3.B.3, SNF -212.3.B.3  In some cases where it is medically predictable that a patient will require a covered level of SNF care within a predeterminable time frame, the individual may also have a need for a covered level of SNF care within 30 days of hospital discharge.  In such situations, this need for covered SNF care does not negate further coverage at a future date even if there is a noncovered interval of more than 30 days between the two stays, provided all other requirements are met.  (See example 1 below.)  However, this rule applies only where part of the care required involves deferred care, which was medically predictable at the time of hospital discharge.  If the deferred care is not medically predictable at the time of hospital discharge, then coverage may not be exte nded to include SNF care following an interval of more than 30 days of noncovered care (see example 2).  Where it is medically predictable that a patient will require a covered level of SNF care within a specific time frame, the fact that an individual ent ers a SNF immediately upon discharge from the hospital for noncovered care does not negate coverage at a later date, assuming the requirements of the law are met (see example 3).   EXAMPLE 1:
(Medicare Benefit Policy Manual)
EXAMPLE 1:   A patient who has had an open reduction of a fracture of the femoral neck and has a history of diabetes mellitus and angina pectoris is discharged from the hospital on January 30, 1991 and admitted immediately to a SNF.  He requires, among other services, careful skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise program to preserve muscle tone and body condition, and observation to detect s igns of deterioration in his condition or complications resulting from his restricted mobility, which necessitates skilled management of his care to ensure his safety and recovery.  It is medically predictable that when he is medically allowed to bear weig ht on the affected limb, skilled rehabilitative services will be required.  After he is in the SNF for two days, he becomes unhappy and at his request is released to his home in the care of a full time private duty nurse.  Five weeks later, when he reaches  weight bearing, he is readmitted to the SNF for the needed rehabilitative care.  The patient would be eligible for coverage under the program for the care furnished him during both of these stays.   EXAMPLE 2:   An individual is admitted to a SNF for daily skilled rehabilitative care that, as a practical matter, can be provided only on an inpatient basis in a SNF.  After three weeks, the therapy is discontinued because the patients condition has stabilized and da ily skilled services are no longer required.  Six weeks later, however, as a result of an unexpected change in the patients condition, daily skilled services are again required.  Since the second period of treatment did not constitute care which was predi ctable at the time of hospital discharge and thus could not be considered as care which was deferred until medically appropriate, it would not represent an exception to the 30- day exception rule.  Therefore, since more than 30 days of noncovered care had e lapsed between the last period of covered care and the reinstitution of skilled services, payment could not be made under the extended care benefit for the latter services.   EXAMPLE 3:
(Medicare Benefit Policy Manual)
EXAMPLE 3:   A patient whose right leg was amputated was discharged from the hospital and admitted directly to a SNF on January 30, 1991.  Although upon admission to the SNF the patient required help with meeting his activities of daily living, he did not require daily skilled care.  Subsequently, however, after the stump had healed, daily skilled rehabilitative services designed to enable him to use a prosthesis were required.  Since at the time of the patients discharge from the hospital it was medically predictable that covered SNF care would be required at a predeterminable time interval, and since such care was initiated when appropriate, the patient would be entitled to extended care benefits for the period during which such care was provided.   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.
(Medicare Benefit Policy Manual)
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.)
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
[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.
(Medicare Benefit Policy Manual)
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)
(Medicare Benefit Policy Manual)
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.