Medicare Part A covers skilled nursing and rehabilitation care in a Skilled Nursing Facility (SNF) under certain conditions for a limited time. Coverage for care in SNFs is measured in ‘benefit periods’ or sometimes ‘spell of illness. In each benefit period, Medicare Part A covers up to 20 days in full. After that, Medicare Part A covers an additional 80 days with the beneficiary paying coinsurance for each day. After 100 days, the SNF coverage available during that benefit period is ‘exhausted,’ and the beneficiary pays for all care, except for certain Medicare Part B services. In this article, we shared Medicare SNF billing coverage for the year 2022, and also we bifurcated Medicare SNF billing coverage for Medicare part A, Medicare part B, Original Medicare, and Medicare Advantage (MA).
Medicare SNF Billing Coverage
Medicare Part A Coverage
The SNF Prospective Payment System (PPS) pays for all SNF Part A inpatient services.
Medicare Part A covers Medicare-certified SNF skilled care. Skilled care is nursing or other rehabilitative services, provided according to physician orders, that:
- Require skills of qualified technical or professional health personnel, like registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists
- Are provided directly by, or under general skilled nursing or skilled rehabilitation personnel supervision, to assure patient safety and medically desired results
- General supervision requires initial direction and periodic inspection of the actual activity; the supervisor isn’t always physically present or at the location when the assistant performs services
Medicare considers a service skilled if its inherent complexity can only be performed safely and or effectively by, or under the general supervision of, skilled nursing or skilled rehabilitation personnel. Under the consolidated billing provision, SNF Part A inpatient services include all Medicare Part A services considered within the scope or capability of SNFs. In some cases, the SNF must obtain some services it does not provide directly. For these services, the SNF must make arrangements to pay for the services and must not bill Medicare separately for those services.
Medicare Part B Coverage
Medicare Part B may pay for some services provided to beneficiaries residing in an SNF whose benefit period exhausted or who are not otherwise entitled to payment under Part A; outpatient services rendered to beneficiaries who are not inpatients of an SNF, and services excluded from SNF PPS and SNF consolidated billing. Bill repetitive services monthly or when treatment stops. Bill one-time services when you complete the service. You can refer Medicare Claims Processing Manual, Chapter 7 for detailed information.
Original Medicare Coverage
Original Medicare enrollees must meet these conditions to qualify for Part A-covered SNF Billing services:
- The patient was a hospital inpatient for a medically necessary stay of at least 3 consecutive calendar days
- Time spent in observation or in an emergency room doesn’t count toward a medically necessary 3-day qualifying inpatient hospital stay
- A Medicare Advantage (MA) plan, 1876 Cost plan, or Program of All-inclusive Care for the Elderly (PACE) plan may waive the 3-day stay for enrollees
- Patient transferred to Medicare-certified SNF within 30 days after hospital discharge, unless both are true:
- The patient’s condition makes it medically inappropriate to begin active treatment in an SNF immediately after discharge
- It’s medically predictable at patient’s hospital discharge that they’ll need covered SNF care within a predetermined time period (generally no more than 30 days), and they meet that prediction
- The patient needs daily skilled nursing or rehabilitation services
Daily skilled services can happen only in an SNF Billing on an inpatient basis if:
- They aren’t available on an outpatient basis in the patient’s location
- When compared to an inpatient setting, transportation to a facility is:
- Excessive physical hardship
- Less economical
- Less efficient or effective
- Services are reasonable and necessary for diagnosing or treating a patient’s qualifying condition and of reasonable duration and quantity
Medicare Advantage Coverage
Medicare Advantage (MA) plans, 1876 Cost plans, or PACE plans typically waive the 3-day hospitalization requirement. MA plans must cover the same number of SNF days Original Medicare covers, but they may cover more. Note that For MA plan patients, check with the MA plan for information on eligibility, coverage, and payment. Each plan can have different patient out-of-pocket costs and specific rules for getting and billing for services. You must follow the plan’s terms and conditions for payment.
- MA plans may offer different benefit periods
- Each MA plan’s Evidence of Coverage (EOC) describes all its benefits, including SNF coverage
- Most MA plans offer SNF coverage through network providers paid according to their contracts
- Non-network SNFs should confirm MA coverage with the enrollee’s MA plan
- MA plans that cover SNF services provided by non-network SNFs pay the Original Medicare payment rate
3-Day Prior Hospitalization
A patient meets the 3-consecutive-day stay requirement by staying 3 consecutive days in 1 or more hospital(s). Only the admission day, not the discharge day, counts as a hospital inpatient day. Time spent in observation or in the emergency room before admission doesn’t count toward the 3-day qualifying inpatient hospital stay.
3-Day Stay Waiver
Certain SNFs that have a relationship with Shared Savings Program (SSP) Accountable Care Organizations (ACOs) may waive the SNF 3-day rule. Occasionally, during a Public Health Emergency, we may issue a temporary waiver. Most MA plans to waive the 3-day hospitalization requirement.
We hope that this Medicare SNF billing coverage for the year 2022 would be helpful in accurately billing Medicare for SNF services. In case of any assistance needed in Skilled Nursing Facility (SNF) billing, contact Medical Billers and Coders (MBC) at info@medicalbillersandcoders.com or call us at 888-357-3226.
FAQs
1. What does Medicare Part A cover for Skilled Nursing Facility (SNF) care?
Medicare Part A covers up to 100 days of care in a Medicare-certified Skilled Nursing Facility (SNF) during each benefit period. The first 20 days are covered in full, and for the remaining 80 days, the patient pays a coinsurance amount.
2. When does Medicare Part A stop covering SNF care?
Medicare Part A stops covering SNF care after 100 days in a benefit period. After that, the patient is responsible for all costs except for certain services covered under Medicare Part B.
3. What services are covered under Medicare Part B in an SNF?
Medicare Part B covers outpatient services, repetitive services billed monthly, and one-time services provided to patients in an SNF when the benefit period under Part A is exhausted or when patients are ineligible for Part A coverage.
4. What are the requirements for Medicare to cover SNF services under Part A?
To qualify, the patient must have had a medically necessary hospital stay of at least 3 consecutive days, be transferred to a Medicare-certified SNF within 30 days, and require daily skilled nursing or rehabilitation services that are only available in an SNF.
5. Does Medicare Advantage cover SNF care the same way as Original Medicare?
Medicare Advantage (MA) plans cover the same number of SNF days as Original Medicare, but they may offer more. Each MA plan may have different rules and out-of-pocket costs, so it’s important to check the plan’s terms for specific details on SNF coverage.
6. What is the 3-day rule for SNF coverage?
The 3-day rule requires that a patient stay as an inpatient in a hospital for at least 3 consecutive days before Medicare Part A will cover SNF care. However, some Medicare Advantage plans and certain programs may waive this requirement.
7. What should SNFs do to bill correctly for services provided under Medicare?
SNFs must ensure accurate documentation, follow the specific rules for Medicare Part A and Part B billing, and check for changes in benefit periods and patient eligibility, especially for Medicare Advantage plans.
