Skilled Nursing

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
  • 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 

 

CA Dept of Aging – Home & Long Term Care ---

Revision  2018 pdf

Please note, there are updates all the time, double check everything.

#Taking Care of Tomorrow

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NAIC Shoppers Guide to Long Term Care

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Long Term Care Nursing & Home Health Care

Home Health Care

Medicare #Home health services

You can use your home health benefits under Part A and/or Part B to pay for home health services. Medicare covers medically necessary part-time or intermittent skilled nursing care, and/or physical therapy, speech-language pathology services, or continued occupational therapy services. A doctor, or certain health care professionals who work with a doctor, must see you face to-face before a doctor can certify that you need home health services. A doctor must order your care, and a Medicare-certified home health agency must provide it.

Home health services may also include medical social services, part-time or intermittent home health aide services, durable medical equipment, and medical supplies for use at home. You must be homebound, which means:

• You have trouble leaving your home without help (like using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of an illness or injury.
• Leaving your home isn’t recommended because of your condition.
• You’re normally unable to leave your home because it’s a major effort.

You pay nothing for covered home health services. You pay 20% of the Medicare-approved amount, and the Part B deductible applies, for Medicare covered medical equipment. copied from Medicare & You – see brochure in side panel *

$1.2 trillion infrastructure package

 

Build Back Better 

November 6, 2021

The bill leaves out Biden’s proposal to spend $400 billion to bolster caregiving for aging and disabled Americans — the second largest measure in the American Jobs Plan.

His proposal would have expanded access to long-term care services under Medicaid, eliminating the wait list for hundreds of thousands of people. It would have provided more opportunity for people to receive care at home through community-based services or from family members.

It would also have improved the wages of home health workers, who now make approximately $12 an hour, and would have put in place an infrastructure to give caregiving workers the opportunity to join a union. CNN Reuters Wikipedia *

Find a Nursing Home

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

How to Find Home Health Care

Continuing Care Retirement Communities (CCRCs)

offer persons 60 years of age or older a long term continuing care contract that provides for independent living units, residential care/assisted living services, and skilled nursing care, usually in one location, and usually for a resident’s lifetime. Most CCRCs require a substantial entrance fee (e.g., from a low of $100,000 to over a million) to be paid by the applicant upon admission along with monthly fees. * CANHR.org  *

 

Continuing Care Retirement Communities

Skilled Nursing vs Sub Acute Care

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

Skilled Nursing Care Livanta the Medicare reviewerappeals 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 

 

  • What is #Subacute Level of Care?
    • 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.1

      SAR is typically provided in a licensed skilled nursing facility (SNF).

      • 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 rehabVery Well.com *

    • 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.
      • There is some confusion, IMHO on if this is Hospitalization or Skilled Nursing dhcs.ca.gov * Cedars Sinai * Knollwood Nursing Center *
    • Subacute care, or subacute rehabilitation (SAR) is care received inpatient when recovering from an injury or illness. The care is usually received in a skilled nursing facility (SNF). Medicare World *
    • Review of the subacute care literature
    • Which patients benefit from Subacute care?
    • B. Subintensive Care Type Units.–Some hospitals have units which provide a level of care between other general routine and intensive care. These units are typically designated as subintensive, subacute, progressive, intermediate care units, etc. CMS.gov *
    • Medicare Benefit Policy Manual Chapter 8 – Coverage of Extended Care (SNF) Services Under Hospital Insurance  CMS.gov *
    • Subacute level of Care in a Skilled Nursing Facility (SNF) under Medicare Part A
    • OVERVIEW: Subacute nursing and rehabilitation services: services, furnished pursuant to physician orders, for members that are in a Skilled Nursing Facility and covered by Medicare Part A, that:• Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists.
      • Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.  and
      • Require a short term, goal-oriented treatment plan including complex skilled nursing care and/or high intensity level skilled rehabilitation.NOTE: Subacute care is generally more intensive than traditional nursing facility care and less intense than acute care.  Common Wealth Care
    • Medical Necessity Guideline
      Some examples of complex medical conditions that may require subacute skilled nursing or rehabilitative care:• Presence of serious injury or illness that requires inpatient treatment but not acute hospital care
      Ventilator Program
      • Complex Respiratory Care and Treatments
      • Specialized Infusion Therapy
      • Brain Injury Rehabilitation
      • High Intensity Stroke
      • High Intensity Orthopedic Program
      • Specialized Post-Surgical Recovery Programs
      • Complex pain management Common Wealth Care

Medicare ​#Appeals  11525

Medicare Appeals

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 Filing an appeal with Medicare

References, Links & Bibliography 

  • Coverage
    • Medicare.Gov  Glossary
    • Definitions 
  • Benefit Period
    • CMS on Benefits Periods Official Detailed Manual
    • Medicare Rights.org
    • Medicare Interactive 
      • Benefit periods measure your use of inpatient hospital and skilled nursing facility (SNF) services. A benefit period begins the day you are admitted to a hospital as an inpatient, or to a SNF, and ends the day you have been out of the hospital or SNF for 60 days in a row. After you meet your deductible, Original Medicare pays in full for days 1 to 60 that you are in a hospital. For days 61-90, you pay a daily coinsurance.

        If you have used your 90 days of hospital coverage but need to stay longer, Medicare covers up to 60 additional lifetime reserve days, for which you will pay a daily coinsurance. These days are nonrenewable, meaning you will not get them back when you become eligible for another benefit period.

        Medicare will stop paying for your inpatient-related hospital costs (such as room and board) if you run out of days during your benefit period. To be eligible for a new benefit period, and additional days of inpatient coverage, you must remain out of the hospital or SNF for 60 days in a row. When you start a new benefit period, you will also have a new Part A deductible.

        Note: Medigap policies A through N pay for your hospital coinsurance and provide up to an additional 365 lifetime reserve days. Additionally, Plans B through N pay some or all of your hospital deductible. Medicare Interactive 

  • Skilled Nursing over 100 days
  • Lifetime Reserve Days
    • Medicare Interactive from Medicare
    • Additional 365 from Medi Gap – EOC Page 4 II A 1 c 
      • c) Upon exhaustion of the Medicare hospital inpatient coverage including the sixty (60) lifetime reserve days, coverage for the Medicare Part A Eligible Expenses for hospitalization will be paid at the appropriate standard of payment which has been approved by Medicare, subject to a lifetime maximum benefit of an additional 365 days (except that psychiatric care in a psychiatric hospital participating in the Medicare program is limited to 190 days during the Subscriber’s lifetime);
      • CA Insurance Code (b) With respect to the standards for basic (core) benefits for benefit plans A to J, inclusive, every issuer shall make available a policy or certificate including only the following basic “core” package of benefits to each prospective insured. An issuer may make available to prospective insureds any of the other Medicare supplement insurance benefit plans in addition to the basic core package, but not in lieu of it. However, the benefits described in paragraphs (6) and (7) shall not be offered so long as California is required to disallow these benefits for Medicare beneficiaries by the Centers for Medicare and Medicaid Services or other agent of the federal government under Section 1395ss of Title 42 of the United States Code.

        • (1) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day to the 90th day, inclusive, in any Medicare benefit period.

          (2) Coverage of Part A Medicare eligible expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used.

          (3) Upon exhaustion of the Medicare hospital inpatient coverage including the lifetime reserve days, coverage of 100 percent of the Medicare Part A eligible expenses for hospitalization paid at the appropriate Medicare standard of payment,

               cms.gov/Physician Fee Schedule
          health care value hub.org/medicare-rates-benchmark-too-little-or-just-right
          AHA.org Fact Sheet
          Kaiser Health News What A Hospital Charges Vs. What Medicare Pays

          medicare vs actual bill

          subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer’s payment as payment in full and may not bill the insured for any balance.

      • (c) The following additional benefits shall be included in Medicare supplement benefit plans B to J, inclusive, only as provided by Section 10192.9.
        • (2) With respect to skilled nursing facility care, coverage for the actual billed charges up to the coinsurance amount from the 21st day to the 100th day, inclusive, in a Medicare benefit period for post hospital skilled nursing facility care eligible under Medicare Part A. CA Insurance Code 10192.8 b 

  • Law, Legal Codes   &  Clinical Guidelines

Medi Gap Summary Graphics

How does Medi Gap Plan Hi F pay for Hospital Care, Long Term #Acute Hospital, Sub Acute Care, Skilled Nursing, Home Health Care

What happens if you go over 90 days? How do 60 lifetime reserve days work? How do 365 additional from Medi Gap work?

 

 

hi f part a hospital

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skilled nursing hi f

5 comments on “Skilled Nursing SNF & Home Health What Medicare Pays

  1. Help!

    I’ve been in the hospital, skilled nursing, etc. since November. Due to an infection my toes were amputated. I need physical therapy, skilled nursing, home health care, Medi Cal, IHSS, I don’t know what all.

    What programs and guarantees are available to me.

    I also have Blue Shield 65 Plus HMO, how is it better and differ from original Medicare?

    • Skilled Nursing Facility Benefits

      Benefits are provided for Skilled Nursing services in a Skilled Nursing unit of a Hospital or a freestanding Skilled Nursing Facility, up to the Benefit maximum as shown on the Summary of Benefits.

      The Benefit maximum is per Member per Benefit Period, except that room and board charges in excess of the facility’s established semi-private room rate are excluded.

      A “Benefit Period” begins on the date the Member is admitted into the facility for Skilled Nursing services, and ends 60 days after being discharged and Skilled Nursing services are no longer being received.

      A new Benefit Period can begin only after an existing Benefit Period ends Specimen Policy

      Summary of Benefits

      Skilled nursing facility (SNF) services Up to 100 days per member, per benefit period,

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