Having a firm grasp of Medicare SNF coverage can be a challenge. Here we will walk long-term care leaders and caregivers through SNF billing requirements, the differences between Medicare Part A and Medicare Part B, and what qualifies a patient for skilled nursing care. But first, we will define our parameters.
What is a SNF? A Skilled Nursing Facility (SNF) is a type of medical care facility that provides both short-term and long-term care to individuals who require specialized medical attention. Adults who are in a SNF are there either because they are recovering from an illness and intend to leave as soon as possible or because they have complex medical needs that may require long-term care.
What kind of care is provided in a SNF? SNFs employ a range of healthcare professionals to provide care to patients from the two categories mentioned above. These caregivers include:
- Registered Nurses (RNs)
- Licensed Practical Nurses (LPNs)
- Certified Nursing Assistants (CNAs)
- Physical therapists, occupational therapists, and speech therapists
- Social workers.
These professionals work together to develop personalized care plans for each patient and resident, taking into account their individual medical needs, abilities, and goals.
Who regulates SNFs? At the federal level, SNFs are regulated by the Centers for Medicare and Medicaid Services (CMS), which oversees the Medicare and Medicaid programs and reimbursement for healthcare services provided by SNFs. At the state level, SNFs are regulated by the Department of Health or similar agencies. Though the state is responsible for certifying SNFs, the certification is still subject to CMS approval. Thus, Medicare SNF coverage is a type of insurance that covers skilled nursing facility services for eligible beneficiaries.
The Medicare SNF Billing Manual
The Medicare SNF billing manual is a resource provided by the Department of Health and Human Services and offers guidance on Medicare SNF coverage, including information about:
- Medicare Part A
- Medicare Part B
- SNF billing requirements
Before diving into the above, it is worth mentioning the conditions under which Medicare will cover SNF stays. For Medicare to cover their stays, seniors must have the following:
- Eligibility for Medicare Part A (hospital insurance) with available days left in their benefit period to use
- A qualifying hospital stay. This is defined as a previous medically necessary inpatient hospital stay of three consecutive days or more, beginning with the day the hospital admits them as an inpatient but not including the day they leave the hospital.
- A physician’s order for inpatient services that require the skills of professional personnel in a SNF, such as CNAs, RNs, and LPNs.
- The need for skilled care (e.g., skilled therapy services) that can only be provided in a SNF on a daily basis.
- The need for such skilled services on account of one of two reasons: either an ongoing condition that was also treated during their qualifying three-day inpatient hospital stay—even if it wasn’t the reason they were admitted to the hospital—or a new condition that started while they were getting SNF care for the ongoing condition
- Reasonable and necessary skilled nursing services administered for the diagnosis or treatment of their condition during their stay
- Skilled services provided specifically in a Medicare-certified SNF
Medicare Part A
Medicare Part A is a health insurance program provided by the federal government that covers inpatient hospital care, skilled nursing facility care, and some home health care services. Part A Medicare SNF coverage is an essential benefit for those who need specialized medical care in a long-term care setting.
As was mentioned, to be eligible for Medicare Part A for SNF coverage, a patient needs to have been hospitalized for a minimum of three days. Following that, within 30 days of hospital discharge, the patient must be admitted to an SNF for specialized custodial or rehabilitation care that cannot be provided elsewhere.
As for the costs:
- Days 1-20 of Medicare Part A cost $0 in coinsurance
- Days 21-100 cost up to $200 in coinsurance
- From days 101 onwards, patients will have to cover their healthcare costs
The benefit of acquiring Medicare Part A is that the following will be covered:
- Semi-private room accommodation
- Skilled nursing care
- Rehabilitation services, including physical therapy, occupational therapy, and speech therapy
- Medications, medical supplies, and equipment necessary for their care
- Dietary counseling and therapeutic diets
- Social services, including counseling and discharge planning
Medicare Part B
In addition to Medicare Part A coverage for SNF stays, seniors may also have coverage through Medicare Part B, which covers many services that may be received in SNFs, including doctor’s visits, lab tests, medical equipment, and supplies, outpatient therapy services, and certain preventive services. These services are often necessary for seniors who require ongoing medical care and rehabilitation services while staying in a SNF.
It is worth mentioning that Medicare will not cover the following items and services:
- Any additional phone and television charges by the facility
- Private duty nursing services
- Personal hygiene items and toiletries
For more, check out our insider tips on SNF billing. And if you’re just looking to understand SNF consolidated billing, learn the guidelines for staying compliant with long-term care billing guidelines, or are looking for medical billing software online, we have you covered as well.
Contact us here if you would like to improve your reimbursements with easy-to-use billing software.
What Qualifies a Patient for Skilled Nursing Care
At this point, the reader has a good understanding of Medicare coverage in skilled nursing facilities. Still, there is much to discuss concerning what qualifies a patient for skilled nursing care. Further, while we have defined what SNFs are when discussing Medicare SNF coverage, we have yet to fully define skilled nursing care and how it relates to a Skilled Nursing Facility (SNF).
Skilled nursing care is a specific type of medical care provided to patients who require ongoing medical attention and assistance with daily activities due to an illness, injury, or chronic medical condition. The settings under which skilled nursing care may be provided include nursing homes, assisted living facilities, and SNFs.
Because the Medicare SNF billing manual is written for long-term care professionals, the SNF billing guidelines included do not specify what qualifies an elderly loved one for skilled nursing care. Here, however, we will look at three distinctive signs to look out for when considering long-term care for a loved one:
- Early non-medical signs:
- Poor hygiene and a generally unkempt appearance
- Obvious weight loss due to bad eating habits
- Missing medication schedules
- Unsteadiness when walking
- Critical medical issues:
- Cardiac failure
- Congestive heart failure
- Chronic obstructive pulmonary disease (COPD)
- Fall-related injuries
- Hip or bone fracture
- Orthopedic surgery
- Parkinson’s disease
- Cognitive concerns:
- Repeatedly asking the same questions
- Disorientation in familiar locations
- Difficulty in following instructions
- Bewilderment about one’s surroundings, time, and well-known individuals
One should seek medical advice from a physician if an elderly loved one is displaying any of these symptoms. At the same, it does not hurt to look into the long-term care options that are available to you.
Medicare SNF Coverage: How Time Impacts a Benefit Period
Long-term care administrators should note that Medicare SNF coverage can be affected by the gap in between between SNF care services. For instance, If a patient is discharged from a SNF and is then readmitted within 30 days, Medicare will typically resume coverage without requiring a new qualifying hospital stay. However, if the patient’s break lasts for more than 30 days, they will need to meet the qualifying hospital stay requirement again in order to receive SNF coverage.
What this time restriction means is that the patient will need to be hospitalized for at least three consecutive days and then admitted to a SNF within 30 days of their hospital discharge to receive Medicare SNF coverage. Meanwhile, if the patient does not receive skilled care for at least 60 days in a row, their current benefit period ends. SNFs should always take these restrictions into account as they fill their UB-04 forms for Medicare SNF coverage reimbursements.
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