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Navigating the skilled nursing benefit for Medicare

Learning objective

At the completion of this educational activity, the learner will be able to:

• Identify strategies to help patients who don’t qualify for inpatient admission find postacute options

Assigning the correct patient status is important not only to ensure that the hospital gets accurate payment for a patient stay, but also to ensure that the patient receives access to the postacute benefits to which he or she is entitled. One of the more problematic topics in this arena is the three-day inpatient stay required by Medicare for a patient to qualify for a covered postacute stay in a SNF. One reader submitted the question below on this topic, and we asked Janet L. Blondo, MSW, LCSW-C, LICSW, CMAC, ACM, CCM, the manager of case management at Washington Adventist Hospital in Takoma Park, Maryland, to supply an answer.

Q: As a case manager, I already know that my patients placed in observation don’t qualify to use their Medicare SNF benefits after a hospital stay. However, family members often oppose a patient’s discharge date, citing safety concerns and demanding that the patient be admitted as an inpatient for three days so that he or she can be transferred to a SNF to use the patient’s Medicare SNF benefit to pay for nursing home care. What do I do when the patient’s family members resist the plan of discharging their loved one home?

A: Family members often become concerned about how their loved one will manage when there is a change in the patient’s ability to provide self-care. An injury or illness that results in a hospital stay?even a short one?can prompt a temporary or permanent loss of function. Patients and families may have some knowledge that insurance could pay for some rehabilitation services.

Beginning in August 2016, the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act requires all hospitals to explain to patients?both verbally and in writing?what it means when they are placed in observation. The NOTICE Act also compels the hospital to inform patients that they do not qualify to use their Medicare SNF benefits to recover from a hospital stay. This may result in more patients demanding that they be admitted for inpatient care.

Despite the current emphasis on population health, few patients have long-term care plans in place. This means that seniors are caught unprepared after a short stay in hospital observation care. They may not be able to return to a home that lacks a 24-hour caregiver or that has stairs they can no longer negotiate.

Patients and family members often believe that their insurance, Medicare, will pay the entire cost for care in a nursing home. They don’t fully understand the difference between skilled versus custodial care, or that if Medicare does provide coverage, it won’t pay the entire cost of care and will cover costs only for a short time.

Since explaining the above information to patients can be challenging, the smart case manager should get busy and assess what options are available to the patient. First, review the situation and determine that the patient truly does not meet inpatient criteria. When in doubt, refer the case to your physician advisor without delay.

The 2016 OPPS final rule, CMS-1633-F, effective January 1, 2016, allows the physician to document the need for inpatient care based on a set of "complex medical factors," which include:

• Severity of signs and symptoms
• Current medical needs
• Risk of an adverse event occurring

Qualifying for inpatient care does not mean a patient must require hospitalization that extends for more than two midnights. If the patient truly does not meet inpatient criteria, next determine if he or she is a candidate for acute rehab. Acute rehab does not require a prior three-day or greater hospital stay. Does your patient have Medicare Part C? A managed Medicare plan does not require an inpatient stay of three days or more, although it does require an authorization for a SNF benefit.

Some secondary payers will cover a rehab stay in a SNF. Look at all of the patient’s insurance policies and call the payers. A Medigap policy will pay only if Medicare pays, which requires a three-day inpatient admission. Some patients, however, are covered by a spouse’s policy or have a policy from a previous job that is not a Medigap policy?these policies will potentially cover a SNF stay.

Ask if the patient has been in a nursing facility prior to the current hospital stay while using his or her Medicare SNF benefits. If the patient was in a SNF after a three-day qualifying hospital stay, and his or her discharge from the SNF was within 30 days of the expected date of admission for the new SNF stay, then chances are the patient’s stay will be covered under Medicare.

Case managers often don’t ask about private-pay funds. Patients may pay privately for care in a nursing home. Ask if the patient has a long-term care policy that will cover the cost. Alternatively, the patient’s family may assist with the funding. Some patients who own a home use a home equity line of credit to pay for the cost or apply for a reverse mortgage.

Applying for long-term care Medicaid is an option, but this can take a long time, and many nursing homes want a source of funding at the time the patient enters the facility.

A patient can also go home with family members who are able to help with care until the patient is able to make a more permanent plan. Family members who work can apply for family and medical leave while they are serving as caregivers.

Adult medical day care facilities also have all-day programs where patients can be cared for during the day while family members work. Patients can receive nursing education about their illness, undergo blood pressure and blood sugar checks, and receive physical and occupational therapy. Payment is provided through sliding-scale or private-pay funding, or by community Medicaid.

Finally, patients may benefit from skilled home health care services, covered by insurance or by private-duty aide care paid for with the patient’s (or family’s) funds.

If, after reviewing these options, none are acceptable to the patient or family, you may have to give the patient the Hospital-Issued Notice of Noncoverage, or HINN, which notifies the patient that you do not anticipate the hospital bill or subsequent rehab will be paid by Medicare. The notice may help the patient determine what course of action to take.

Editor’s note: Got a question? Email it to us and we’ll send it to one of our experts. Send questions to Kelly Bilodeau at [email protected].

HCPro.com – Case Management Monthly