Revision 12-3; Effective September 1, 2012

 

H-7100 General Information

Revision 09-4; Effective December 1, 2009

 

Under Title XVIII of the Social Security Act, Medicare Part A coverage includes payment for limited nursing facility (NF) care as an extension of hospital care.

Medicare covers a maximum of 100 days in a skilled nursing facility (SNF), also referred to as extended care facilities. A team, consisting of physicians and nurses, determines whether the person meets Medicare's criteria for SNF at admission and at weekly reevaluations. Many persons do not use the entire 100 days, or may have hospital readmissions during their SNF period. A return to the hospital is not part of the available 100 days.

Medicare covers all charges for the first 20 days of SNF care. The following 80 days are coinsurance days. Medicare covers all of the medical expenses during this period; the person pays a coinsurance rate toward room and board. Medicare-covered services in an NF include skilled nursing care, physician services, physical/occupational/speech therapy, prescriptions, routine dental care and room and board.

For a Medicaid applicant or person who is certified for Medicare payments while in a Medicare SNF, Medicare pays the entire bill for the first through the 20th day. There is no coinsurance for that period. The person is eligible for coinsurance vendor payment beginning on the 21st day. Coinsurance continues through the 100th day if the person's stay is covered by Medicare.

A person can be certified for Medicaid during the entire SNF period, provided the person resides in a Medicaid NF. A co-payment is calculated for the coinsurance period, with vendor payment covering the balance of the SNF rate. There is no co-payment for the first 20 days of full SNF coverage.

Notes:

  • Begin the eligibility determination process when a person files an application for Medicaid upon admission to the Medicare-SNF part of a Medicaid facility.
  • Because the person must have been in a hospital for at least three days before SNF admission, always explore prior medical coverage. Reminder: The special income limit is applicable once the person (or couple) has been confined to one or more Medicaid-approved long-term care facilities (Medicare-SNF, NF or ICF/MR) for at least 30 consecutive days.
  • Accept the Medicare determination of need for SNF care as a medical necessity determination.
  • The NF must submit documentation that sets the rate at which the facility is paid.

Under certain limited conditions, Medicare will pay some NF costs for Medicare beneficiaries who require skilled nursing or rehabilitation services. To be covered, the person must receive the services from a Medicare-certified SNF after a qualifying hospital stay. A qualifying hospital stay is the amount of time spent in a hospital just before entering a nursing facility. This is at least three days. Care must begin within 30 days after leaving the hospital. The person’s doctor must order daily skilled nursing or rehabilitation services that the person can get only in an SNF. "Daily" means seven days a week for skilled nursing services and five days a week or more for skilled rehabilitation services.

 

H-7200 Medicare-Related Financial Responsibilities for Skilled Nursing Facility Care

Revision 09-4; Effective December 1, 2009

 

Number of Days Person's Responsibility Medicare's Responsibility
1-20 Nothing Everything
21-100 20% skilled nursing facility care co-payment per day paid after 20 days of care (21-100). See Appendix XXXI, Budget Reference Chart. The rest
Over 100 Everything Nothing

 

H-7300 Medicaid Coverage Issues Related to Nursing Facility Costs

Revision 12-3; Effective September 1, 2012

 

  • Community Attendant Services (CAS) (ME-Community Attendant) coverage, provides Medicaid payment for attendant care only. This coverage does not provide for nursing facility (NF) vendor payment, doctor visits, hospital stays, medically necessary items or prescription drug coverage.
  • Regular Medicaid coverage provides Medicaid payment for NF vendor payment, doctor visits, hospital stays, medically necessary items or prescription coverage. Medicaid is the payer of last resort and a medical necessity is required for vendor payment in an NF. Vendor payment is also subject to co-payments. Medicaid coverage provides for payment of prescription drug coverage, except when the person is dually eligible for both Medicare and Medicaid.
  • Qualified Medicare Beneficiary (MC-QMB) coverage indicates that Medicaid pays the Medicare premiums, deductibles and co-insurance, including Medicare-covered hospital and NF stays.

Examples:

Recipient 1 — When a person with only MC-QMB (also known as a Pure Q) enters a skilled nursing facility (SNF) from a hospital, Medicare will cover 100% of the SNF vendor costs for days 1-20. Medicare will cover 80% of the SNF vendor costs for days 21-100. As a Pure Q person, Medicaid's Q covers 100% of the remaining 20% of the SNF vendor costs for days 21-100. The person will not be responsible for the remaining 20% of the SNF vendor costs (the Medicare co-payment per day for days 21-100). As a Pure Q person, the person is not responsible for the amount of co-payment a Medicaid person must pay for nursing care.

Note: If the person does not remain a Pure Q recipient and becomes certified for full Medicaid, use the Recipient 2 example.

Recipient 2 — When a person living in the community enters an SNF from a hospital and is dually eligible for both Medicare and Medicaid (MQMB), Medicare will cover 100% of the SNF vendor costs for days 1-20. Even though the person is Medicaid eligible, test the person for institutional coverage that is subject to transfer of assets and excess home equity policy. The 30-day stay requirement is not necessary. If the recipient is Medicaid eligible for vendor payment:

  • Make retroactive adjustments to ensure the correct benefits are reflected in the system of record if necessary.
  • The recipient will not be responsible for the remaining 20% of the SNF vendor costs (the Medicare co-payment per day for days 21-100).
  • The recipient will have a calculated Medicaid co-payment beginning day 21 and continuing.
  • Notify the recipient of the responsibility for the Medicaid co-payment.

Recipient 3 — When a CAS recipient (ME-Community Attendant) recipient who has Medicare but not MC-QMB enters an SNF from a hospital, Medicare will cover 100% of the SNF vendor payment for days 1-20. Medicare will cover 80% for days 21-100. The recipient’s Medicaid eligibility in an NF needs to be determined. Test the person for institutional coverage that is subject to transfer of assets and excess home equity policy. The 30-day stay requirement is necessary. If the recipient is Medicaid-eligible for vendor payment:

  • Make retroactive adjustments to ensure the correct benefits are reflected in the system of record if necessary.
  • The recipient will not be responsible for the remaining 20% of the SNF vendor costs (the Medicare co-payment per day for days 21-100).
  • The recipient will have a calculated Medicaid-co-payment beginning day 21 and continuing.
  • Notify the recipient of the responsibility for the Medicaid-co-payment.

If the person is not Medicaid-eligible for vendor payment and is not eligible for Pure Q, use the chart in Section H-7200, Medicare-Related Financial Responsibilities for Skilled Nursing Facility Care. Deny the person and send the appropriate denial notice. There will not be a calculated Medicaid-co-payment.

Recipient 4 — When a CAS (ME-Community Attendant) recipient with Qualified Medicare Beneficiary (MC-QMB) only enters an SNF from a hospital, Medicare will cover 100% of the SNF vendor payment for days 1-20. Medicare will cover 80% for days 21-100. The recipient's Medicaid eligibility in an NF needs to be determined. Test the person for institutional coverage that is subject to transfer of assets and excess home equity policy. The 30-day stay requirement is necessary. If the recipient is Medicaid eligible for vendor payment:

  • Make retroactive adjustments to ensure the correct benefits are reflected in the system of record if necessary.
  • The recipient will not be responsible for the remaining 20% of the SNF vendor costs (the Medicare co-payment per day for days 21-100).
  • The recipient will have a calculated Medicaid-co-payment beginning day 21 and continuing.
  • Notify the recipient of the responsibility for the Medicaid-co-payment.

If the person is not Medicaid eligible for vendor payment but is eligible for Pure Q, notify the recipient and use the Recipient 1 example.

 

H-7400 Medicare and Medical Effective Date

Revision 09-4; Effective December 1, 2009

 

The medical effective date for a person in a Medicare skilled nursing facility (SNF) potentially can be as early as the first day of the month of entry to the nursing facility or the first day of a prior month. If eligible, this will ensure payment of any other medical expenses (including returns to the hospital during the initial 20 days of full Medicare coverage). At certification, the eligibility worker must verify and document in the case record that either the person:

  • remains in the SNF section, or
  • has been discharged to Medicaid.

Medicare approval of the applicant for the SNF meets the medical necessity (MN) requirement. If the medical effective date (MED) is prior to the applicant's move to Medicaid days in the facility, the MN requirement has been met.

Note: If the person remains in the SNF when the case is certified, it is recommended that a special review be scheduled to monitor for the completed MN determination when SNF does end.

Examples:

  • Marsha Ford is admitted to an SNF as full Medicare on 11-15-XX. The 21st SNF day is 12-05-XX. Form H1200 is received 12-14-XX. Application is ready to certify 01-03-XX. The eligibility worker verifies that the person has unpaid/reimbursable hospital bills for 11-XX. Ms. Ford is still in the SNF days and has met all eligibility criteria as of 12:01 a.m. 11-01-XX. MED = 11-01-XX. Co-payment begins 12-05-XX.
  • Fred McDaniel is admitted to an SNF as full Medicare on 03-24-XX. The 21st SNF day is 04-13-XX. Form H1200 is received 04-05-XX. He is discharged from the SNF to Medicaid on 05-20-XX. Application is ready to certify 06-15-XX. Mr. McDaniel meets all eligibility criteria as of 12:01 a.m. 03-01-XX. MED = 03-01-XX. Co-payment begins 04-13-XX. MN is not necessary, as MED is prior to discharge to Medicaid.