Below is an overview of the different types of care and
payers in a nursing facility1. Medicare Part A- Skilled Care – Traditional MedicareSNF (different names but all mean the same)
Medicare has four partsMedicare A- (inpatient, such as hospital, rehab or skilled nursing)
Medicare B- (outpatient, such as doctor visits, lab,xrays, therapy)
Medicare C- (replaces Medicare A with an insurance plan)
Medicare D- pharmacy benefit
If a resident is eligible for Medicare Benefits and has Part A (inpatient benefits), and
meets certain medical criteria (one of the criteria would be having at least a 3 night stay
in a hospital-called a “qualifying stay”) , then they can be admitted to Skilled Care in our
nursing facilities.
Medicare Part A will pay for care up to 100 days (as long as it is medically needed). A
resident that would no longer want to participate in therapy or improves dramatically
would be a reason they would not stay in skilled for 100 days.
During those 100 days, Medicare will pay the first 20 days in full. The resident has no
financial responsibility. For up to the next 80 days in 2021, they are responsible for
$185.50/day (often called co-insurance). Medicare will pay us the RUG (now called
HIPPS) score in full for 20 days and starting on day 21, that rate minus the $185.50/day.
(RUG/HIPPS score is based on the assessment done by the MDS nurse showing the
care we are providing to the resident and is automatically entered into PCC, it can be
different for each skilled resident).
Example:
HIPPS rate determined by
MDS assessment
Medicare A, first 20 days
Medicare A, for remaining
days used up to 80
Medicare A Coins from Ins
(from an insurance
supplement
Medicare A Coins from
Medicaid
Medicare A Coins from
Private
$500/day
$500 per day
$500/day $500- $185.50 per day
AND
OR
OR
OR
$185.50/day (but may have deductible or
limited days- resident may still owe a small
amount)
$185.50/day (resident owes nothing)
$185.50/day (resident owes this
him/herself)
This has to be identified correctly in PCC on the Payer Tree. There should always be a
Primary and Secondary Payer identified for Part A.
We use the Medicare Tracker Excel Spreadsheet to keep an accurate account of how
many days the resident has used. If a resident leaves and returns without a wellness
period (defined below) , you must enter the amount of days used previously on the
census line in both PCC and on the tracker continue from that point.
Leave of Absence/ Interrupted Stay – If a Medicare A resident has to go to the hospital
and is there at midnight, that is a leave of absence or interrupted stay. It will be marked
on the census as IS and the facility is not reimbursed for that day. If the resident does
not return before the 3rd day, they are discharged from the day they left.
Exhausted Days- There may be times when a resident is still receiving skilled care and
has reached their 100th payable day. Although we would change the primary payer, the
resident remains at a skilled level of care and cannot begin a “wellness period”.
Continue to keep the resident on the Medicare Tracker, counting past 100 days, to alert
the biller to send correct claim to Medicare. This information will be given to you at the
UR meetings.
Wellness Period – this is a 60 day period where a resident can renew their 100 day
skilled benefit if they remain out of acute care and skilled care for 60 days following a
skilled stay. If 100 days are used and resident enters an inpatient hospital stay or
continues to receive skilled care in the nursing facility, the wellness period will not begin
until either is completed. (Example- resident used 100 days from 1/1/21 to 4/11/21. The
only way Medicare would pay for skilled care again is if the remained out of the hospital
for 60 days or until 6/11/21. If a resident uses only 50 days, they would have 50 days
remaining if needed but would only go back to 100 days if they stayed out of hospital
and or SNF for 60 days).
Discharge Notification (ABN/Notice of Non-Coverage Form) – we are required to notify
the resident that skill care is ending 48 hours before the discharge date. This gives the
resident an option to appeal the decision of ending skilled care (rarely happens).
Corporate Billing office is responsible for collection.
Medicare Part B- Outpatient Therapy
Medicare Part B will pay for the resident’s doctor office visits, labs, xrays, etc and
therapy when they are not on skilled care (remember, to have skilled care certain
criteria must be met, determined by clinical staff). In the nursing facility, a resident may
need limited therapy (3 days a week, rather than the intensive 5 day a week for snf) to
maintain the strength, referred to as outpatient therapy even though they remain in the
building. It is in addition to the Room and Board paid by Medicaid or Privately. Part B
will pay for this at 80% of the charges after a yearly deductible. The “co-ins” would be
20% and either come from Medicare B coin from insurance, Medicare B co-ins from
Medicaid or Medicare B co-ins from Private.
Benefits must be verified before each “start of care”.
Medicare C -Managed Care/ Medicare Replacement Plan/
Option C/
A resident that is eligible for Part A Medicare Benefits can choose to “opt out” of
traditional Medicare Benefits and select an insurance company offering Medicare
Replacement Plans. Humana, Advantage, United Health, Blue Cross, Wellcare are a
few of the most common ones offering that option in this area. Although they follow
Medicare guidelines, they can change plan benefits. It is crucial to verify benefits and
determine if authorization is needed. The Intake team will initiate the authorization but
the facility must follow up as needed to obtain approved days throughout the stay as
these companies only authorize a few days at a time (as opposed to Medicare
automatically giving 100 days if medical necessity is met). Re-certification are needed
as determined by the insurance company to get more days.
They will also have a copay due. It can vary from one insurance company to another.
Secondary Payer on the Payer tree must be setup with the choices Managed Care
CoIns from Medicaid or Managed Care Coins from Private.
They should also be tracked on the Medicare Tracker. Although they do not have a
wellness period while on Managed Care, they are still Medicare beneficiaries and
Medicare requires that we send an “informational bill” to Medicare to show they are
using skilled days.
Corporate Billing Office is responsible for collection.
Medicare Part D- Drug Plan/Pharmacy Plan/ RX plan –
This is a Medicare benefit that allows a resident to choose an insurance plan that will
pay for their medicine.
Medicaid and Resident Liability for LTC stays
If a resident needs to be in a nursing facility (as certified by Form 142) but does not
qualify for skilled care, they can apply for Medicaid to cover their room and board
charges. This is often referred to as Long Term care or sometimes Custodial Care.
Medicaid will review their application and determine if they qualify. Their resources
(things they own besides a home/one vehicle) and cash must be under $2000 but there
are exceptions. (This is a very general statement, it is complicated on what they can
have and if a spouse is involved).
If approved, Medicaid will pay the cost of their care for Room and Board, for the rate
specified in the quarterly rate letter, determined by information that our clinical staff
submits to La DHH (Louisiana Dept of Health and Hospitals), minus their liability
amount.
The resident liability amount (often called PLI or RL) is generally their current income
minus $38.00. The liability amount and the Medicaid payment together total the amount
La. DHH has determined. Resident liability will vary between residents because each
income amount is different. However, regardless of their income, each resident can only
keep $38 for their general spending allowance.
Resident liability is a monthly amount, regardless of days in a month. However if they
discharge, or change payers , it converts to a daily rate. To determine the daily rate of
resident liability the formula is:
Liability amount x 12 months divided by 365 days = daily rate.
Ex:
Liability amount is $1000 month. Formula to get daily rate would be:
$1000 X 12 (months) divided by 365 (days) = $32.88. Daily rate would be $32.88.
Refer to Medicaid Leave Rules on Census guideline. But a quick review is:
Medicaid will reduce the rate they pay us while on leave after 24 hours. It does not
follow the midnight rule. Medicaid allows up to 7 hospital leave days per hospital
confinement and 15 days per year for home leave. A resident must re-establish
residency for 24 hours for leave rate to end. Ex: if resident is out for 5 days and returns
on 12noon on the 10th, but then leaves again at 5pm, it is just like he never returned –
the leave continues. If a resident remains on leave after 7 days, Medicaid no longer
pays for their room and board but we can continue to charge the resident a bedhold fee,
which is the same amount as their daily PLI.
In PCC for a Medicaid resident, the Primary Payer is Medicaid and the secondary payer
is Resident Liability. Even if the liability is $0, PCC should always list primary and
secondary payer. Medicaid residents can also have a 3rd and 4th payer if they are
getting “outpatient” therapy services. Outpatient Therapy (often called Part B therapy) is
when a resident is getting therapy, but not a skilled level of care. Outpatient therapy
usually means the resident is getting 3 days of therapy per week. If a Medicaid resident
has Medicare Benefits, it is always wise to set that information up as the 3 rd payer and
the 4th payer would be their co-insurance. If a resident has Managed Care, they would
also be setup as the 3rd payer with the outpatient version.
To sum it up, if a resident has Medicaid listed as the primary payer, the facility would
actually collect from Medicaid and the resident and possibly from Part B and co-ins for
their stay.
Accurate and timely completion of 148 forms have a direct impact on collection from
Medicaid.
Corporate Billing Office is responsible for collection of Medicaid and the Facility will
collect Resident Liability portion.
Hospice ResidentsIf a resident is Medicaid Eligible but chooses Hospice Care- they will be coded in PCC
as Hospice. The name of the Hospice company should be entered on the PCC “ins” tab.
The CCI billing office will bill hospice for payment. (Louisiana guideline says Hospice
bills for Room and Board and then hospice pays the facility). Otherwise, same rules as
Medicaid apply for the liability portion.
It is rare for hospice resident to have home leave or hospital leave. Usually in that case,
the resident has opted out of Hospice and resume traditional Medicaid/medicare
coverage. Communication with corporate billing office when this happens.
If a resident is NOT Medicaid eligible, they would be coded as Hospice Private and the
resident is responsible for paying for their room and board charges.
Private Pay Residents LTCIf a resident has no other Long Term Care Coverage, they would be responsible for
paying for their Room and Board charges. The fee is set by the facility. The resident
would pre-pay at the beginning of the month for that month of services. Facility is
responsible for collection.