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 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 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 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 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 firstname.lastname@example.org or call us: 888-357-3226.