Post Acute: Skilled Nursing Facilities/Long Term Care

Overview¹

An SNF is an institution or a distinct part of an institution such as a skilled nursing home or rehabilitation center, which has a transfer agreement in effect with one or more participating hospitals and which:

• Is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care; or rehabilitation services for the rehabilitation of injured, disabled, or sick persons; and
• Meets the requirements for participation in §1819 of the Social Security Act and in regulations in 42 CFR part 483, subpart B.

Guidelines for Skilled Nursing Facility

Eligibility Requirements²

Post-hospital extended care services furnished to inpatients of a skilled nursing facility are covered under Medicare Part A. Residents with Medicare Part A coverage are entitled to have payment made on their behalf for the reasonable cost of covered extended care services furnished by the facility, by others under arrangements with the facility, or by a hospital with which the facility has a transfer agreement.

• For Medicare Part A to cover extended care services, the individual must have been an inpatient of a hospital for a medically necessary stay of at least 3 consecutive calendar days.
• Transfer to a participating skilled nursing facility must be within 30 days of discharge from the hospital.
• The individual must require skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel:
  • Personnel include registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech pathologists or audiologists; and
  • Services must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.
• The individual must require these skilled services on a daily basis. As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF:
  • Daily Skilled Services Defined. – Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a "daily basis", i.e., on essentially a 7-day-a-week basis.
• If requirements are not met, a stay in a SNF, even though it might include the delivery of some skilled services, is not covered. For example, payment for a SNF level of care could not be made if a resident needs an intermittent rather than daily skilled service.

Role of MDS 3.0 Assessment

Minimum Data Set (MDS)³

The MDS is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The items in the MDS standardize communication about resident problems and conditions within facilities, between facilities, and between facilities and outside agencies.

The MDS 3.0 contains extensive information on the resident’s nursing needs, Activities of Daily Living (ADL) impairments, cognitive status, behavioral problems, and medical diagnoses. This information is used to define Resource Utilization Group-III (RUG-III) groups that form a hierarchy from the greatest to the least resources used. Residents with more specialized nursing requirements, licensed therapies, greater ADL dependency or other conditions will be assigned to higher groups in the RUG-III hierarchy. Providing care to these residents is more costly, and is reimbursed on a higher level.

MDS Assessment Intervals for Skilled Residents⁴

MDS and RUG re-classification is done at regular intervals during the 100-day benefit period. The per diem rate is adjusted to reflect resources required to provide care throughout the benefit period. Assessments are done on Admission (by day 5), and days 14, 30, 60, and 90.

MDS Assessment Intervals for Non-Part A Residents

An MDS assessment is completed on admission and quarterly for all residents. An additional MDS is required if there is a Significant Change in Care (SCIC) – if the resident shows a significant improvement or deterioration.

Medicare and other sources of payment

Skilled Nursing PPS Model⁵

Sources of Payment for LTC⁶

Coverage of Medical Supplies

Coverage of supplies under Part A

All medical supplies, including dressing, ostomy supplies, urinary catheters and collection devices, fecal collectors and NPWT devices are included in the Part A PPS payment.

Coverage of ostomy supplies under Part B

Medical supplies including dressings, ostomy supplies, urinary catheters and collection devices, are provided to Medicare patients under the Medicare Part B benefit. The facility has the option to provide the supplies and bill Medicare directly, or have the supplies furnished by a Medicare supplier who bills Medicare on behalf of the patient.

At this time, fecal collectors are not covered under Medicare Part B.

Durable Medical Equipment such as NPWT devices are not covered under the Part B benefit to residents of long term care facilities.