Skilled nursing facility care

 

Medicare covers semi-private rooms, meals, skilled nursing and rehabilitative services, and other medically necessary services

(Clinical Guidelines – Oscar – Explains Medical Necessity Requirements so much better and in logical order!) 

and supplies furnished in a skilled nursing facility after a 3-day minimum, medically necessary, inpatient hospital stay ^{Medicare Policy Manual} * ^{Publication 10153 SNF} * for a related illness or injury. An inpatient hospital stay begins the day the hospital formally admits you as an inpatient based on a doctor’s order and doesn’t include the day you’re discharged. You may get coverage of skilled nursing care or skilled therapy care if it’s necessary to help improve or maintain your current condition.

A SNF is a care center where nurses and nursing assistants are available to provide twenty-four hour care for patients to assist them with conditions in their transition between the hospital and a lower level of care such as the home. A SNF may also  provide rehabilitation in order to improve the member’s function and decrease the burden of care. ^{Oscar Clinical Bulletin} *

 

To qualify for skilled nursing facility care coverage, your doctor must certify that you need daily skilled care (like intravenous injections or physical therapy) which, as a practical matter, can only be provided in a skilled nursing facility if you’re an inpatient.

You pay:

• Nothing for the first 20 days of each benefit period
• $185 Coinsurance per day for days 21–100 of each benefit period
  • Sample Medicare Advantage Copay
  • Medicare Advantage must pay at least as well and same qualifications as Original Medicare.
  • MAPD can’t do “funny stuff” or they can get busted for Risk Adjustment Fraud
  • Sample Medi Gap
• All costs for each day after day 100 in a benefit period ^{Medicare.Gov SNF} *

Medicare doesn’t cover long-term care or custodial care.

 

Medical Requirements

The beneficiary needs daily skilled care or rehabilitation services as ordered by a physician. These skilled services can only be rendered by, or under the direct supervision of, skilled nursing or rehabilitation staff. In addition, the skilled services the patient receives must be for a medical condition they were treated for during the three-day qualifying hospital stay, or for a condition that arose during that hospital stay or while the patient was receiving Medicare-covered SNF care.

The requirement of “daily” skilled services should not be taken so literally that occasional sessions missed due to holidays or illness will make the patient not meet the daily requirement for skilled services.

See Oscar’s Clinical Guidelines – It’s explained so much better! 

 

 

Daily Skilled Services Defined

Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a “daily basis,” i.e., on essentially a 7-days-a week basis. A patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the “daily basis” requirement when they need and receive those services on at least 5 days a week. (If therapy services are provided less than 5 days a week, the “daily” requirement would not be met.) ^{Medicare Benefits Policy Manual  SNF Services} 

 

Links & Resources

True Freedom Home Health Plan – Enroll BEFORE you need it. 

Nolo on Inpatient Stays 

 

Finding and #Choosing the right Nursing Home & Home Health Care for you or a loved one 

• Medicare.Gov Nursing Home finder, guide & Compare  This government provided tool also allows you to see what insurances and public benefits are accepted at the various facilities.
• Medi-Cal,
  • IHSS Medi Cal In Home Supportive Services
• Home Health Care Publication # 10969
• Private – Individual  Long Term Care Coverage.
• Sunnyside Nursing & Post Acute Care – Torrance CA
• Veteran’s Home Health Care  va.gov
• Veteran’s Care Co-Ordination.com
  • Aid & Attendance
• Health Grades.com – they charge a fee
• Jewish Free Loan Assoc.
• Medicare.Gov Home Health Provider Finder
• Freedom from abuses Code of Federal Regulations (C.F.R.), 42 CFR 483.12
  • Physician’s Report for Residential Care Facilities for the Elderly (RCFE) Preplacement Appraisal Information LIC 603 Identification and Emergency Information LIC 601     Senate Reviews Assisted Living Facility Problems 2.2014 CA Health Line

How to Find Home Health Care

• Senior Living and Care Options

• New Life Styles.com
  • Independent Living
  • Assisted Living
  • Care Homes
  • Respite Care
  • Memory Care
  • Nursing Homes
  • Home Care
  • Hospice Care
  • Products & Services
• Find & compare nursing homes, hospitals & other providers near you Medicare.Gov
  • Learn more about providers
• 24 hr cares.com  Home Care Provider  –  owned by the son of a friend of ours
• modern health care.com/post-acute-care/nursing-home-care-broken-us-panel-reports  4.6.2022

 Sub Acute Care vs Skilled Nursing #needed – Qualify for and the proper insurance plan.

Skilled Nursing Care Livanta the Medicare reviewer – appeals denied – Medical Necessity 

excerpt of  denial letter.

A review of the medical record shows that the patient was admitted to the skilled nursing facility after hospitalization for difficulty breathing and weakness.

The patient is now receiving skilled services for decreased functional mobility. The patient has made poor progress and is unable to walk, needing help for bed mobility and transfers. The patient needs moderate help for upper body dressing and totally dependent for lower body bathing, toileting and lower body dressing.

There is no documented evidence that continued skilled services are needed on a daily basis to maintain or prevent decline.

There are no documented medical issues to support the need for daily skilled nursing care.

FYI not that it applies here, but a 4.27.2022 HHS Office of the Inspector General report found that MAPD plans denied 13% of prior authorizations that would have been covered under original Medicare (Medi Gap, just follows what Medicare pays.) 

“sub acute care” as opposed to SNF Skilled Nursing Facility

Subacute patients are medically fragile and require special services, such as inhalation therapy, tracheotomy care, intravenous tube feeding, and complex wound management care.

Adult subacute care is a level of care that is defined as comprehensive inpatient care designed for someone who has an acute illness, injury or exacerbation of a disease process.

Pediatric subacute care is a level of care needed by a person less than 21 years of age who uses a medical technology that compensates for the loss of a vital bodily function. DHCS Medi Cal *

Provider criteria for participation in the Subacute Care Program:

Licensed as an acute care hospital with a distinct part (DP), skilled nursing facility (SNF), or
Licensed as a freestanding (FS) SNF, and
Certified as a long term care Medicare and Medi-Cal provider, and
History of compliance with the DHCS Licensing and Certification program, and
Professional staff with the ability to provide care to subacute patients either by experience or demonstrated competence.
When a provider meets the criteria the DHCS enters into a contractual agreement to provide services to Medi-Cal subacute patients.

When a DP/FS SNF meets the criteria the DHCS enters into a contractual agreement, with the facility, to provide services to Medi-Cal subacute patients. DHCS Medi Cal *

Medi Cal sub acute care program, eligibility and treatment procedures

When you are ready to leave the hospital, you may need more medical care and rehab as part of the next step before you can go home. Your Cedars-Sinai care team may arrange for you to go to a sub-acute unit at a nursing facility while you are still healing and getting your strength back. Cedars Sinai *

Sub acute rehab (also called subacute rehabilitation or SAR) is complete inpatient care for someone suffering from an illness or injury. SAR is time-limited with the express purpose of improving functioning and discharging home.

SAR is typically provided in a licensed skilled nursing facility (SNF). SAR is typically paid for by Medicare or a Medicare Advantage program.

SAR provides help in two different areas:

Licensed physical, occupational and speech therapists provide therapy to increase your strength and functioning. For example, depending on what your need is, they might work to:

Increase your balance
Improve your safety when walking
Work to help you move your legs again after a stroke
Improve your independence with activities of daily living (ADLs)
Improve your cardio (heart) fitness after a heart attack
Licensed nursing staff provides medical care such as:

Wound management
Pain management
Respiratory care
Other nursing services that must be provided or supervised by an RN or LPN

SAR vs. Acute Rehab vs. Hospital

The terms used to talk about medical care and rehabilitation can be confusing at times. SAR is different from a hospital or an acute inpatient rehabilitation center.

A hospital, which is sometimes called “acute care,” is appropriate only for significant medical issues with the goal of a very short stay.

An acute rehab center is designed for high-level rehab needs, typically requiring more than three hours a day of physical, occupation, or speech therapy.

Sub acute rehab (SAR) centers are usually most appropriate for people who need less than three hours of therapy a day, thus the label of “sub acute,” which technically means under or less than acute rehab. Very Well.com * knollwood *

If we change plans by March 31 for MAOEP Medicare Advantage Open Enrollment Period, can we get a secondary or supplemental plan to pay for Long Term Care, Sub Acute Care or the $185 Skilled Nursing Co Pay?

Resources & Links 

 

• Medicare Coverage for Skilled Nursing Publication 10153
• Home Health Care # 10969
• Excerpts from Typical MAPD policy on Skilled Nursing, Home Health,
• Insurance Companies need to make a profit and take in 20% more than they pay out in claims. Medical Loss Ratio and all.
• CA Department of Health Care Services — Sub acute Care
• In home supportive care Medi Cal – Medicaid
• Physical therapy Medicare Rules…
• Medicare Website Skilled Nursing SNF
• Our Webpage Medicare Skilled Nursing & Home Health Care
• Here’s our webpage on physical therapy
• See above for the Medicare Pamphlet & Video on Home Health Care
• Medi Cal Aged & Disabled Program
• Medi Cal IHSS In Home Supportive Services
• Appeals & IMR Independent Medical Review
• Requirements to qualify for Skilled Nursing Care
• Physical & Speech Therapy
• Requirements for Physical & Occupational Therapy
• nolo.com/medicare-coverage-inpatient-rehabilitation-stays
• Medicare.Gov MAPD Medicare Advantage Plans must cover all Medicare Services!
• Medicare Quality of Care Complaint Form
• Medi-Cal Medicaid Long Term and Nursing Home coverage – Estate Recovery
• Medi Cal Medicaid Share of Cost
• Risk Adjustment Fraud
• Livanta – Medicare Contractor to make sure MAPD meets Medicare guidelines
• Our webpage on Long Term Care
• Our webpage on Blue Shield Medicare Advantage
• Medical Necessity Clinical Guidelines and go step by step and show the evidence in the medical records that you need skilled nursing care and services on a daily basis to maintain or prevent decline?
• How about Medicare’s Home Health Care benefits? Can you get your doctor to write up a program of care that meets the Home Health Care guidelines?
• Medi Cal IHSS In Home Supportive Services?
• CA Department of Health Care Services — Sub acute Care
• In home supportive care Medi Cal – Medicaid
• Physical therapy Medicare Rules…
• Medicare Website Skilled Nursing SNF
• Our Webpage Medicare Skilled Nursing & Home Health Care
• Requirements to qualify for Skilled Nursing Care
• Physical & Speech Therapy
• Requirements for Physical & Occupational Therapy
• Medicare.Gov MAPD Medicare Advantage Plans must cover all Medicare Services!
• Medicare Quality of Care Complaint Form
• Medi-Cal Medicaid Long Term and Nursing Home coverage – Estate Recovery
• Medi Cal Medicaid Share of Cost
• Risk Adjustment Fraud
• Livanta – Medicare Contractor to make sure MAPD meets Medicare guidelines
• Our webpage on Long Term Care
• Our webpage on Blue Shield Medicare Advantage
• See the MAOEP Medicare Advantage Open Enrollment Period as opposed to AEP Annual Enrollment Period above on the rules and deadlines to change MAPD Plans, Rx Plans and/or go back to original medicare.
• Getting a Medi Gap plan is NOT guaranteed. Here’s our webpage on when Medi Gap is guaranteed. Maybe you qualify or can get in through passing underwriting?
• You can shop and compare Medicare Part D Rx and Medicare Advantage Plans with ALL companies nationwide here.
• If you go with California Blue Cross, United Health Care or Blue Shield please come back to us to enroll. We don’t get paid for providing this website. We only get compensated from the Insurance Company, at no additional cost to you when you enroll though us.
• FAQ on Medi Gap Coverage – Medicare Primary