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  1. Home for the Holidays: Leaving the Nursing Home During a Medicare-Covered Stay
  2. Two Weeks Left in Medicare Enrollment Period
  3. Medicare Advantage Plans Impede Access to Care: Case Study #2
  4. Issue Alert – Medicare Benefit Periods Under PDPM

Home for the Holidays: Leaving the Nursing Home During a Medicare-Covered Stay

Late November begins a time for gatherings with family and friends – Thanksgiving, soon followed by the December holidays. Nursing home residents often want to participate in these gatherings but may worry that they will lose Medicare coverage if they leave the facility to do so. Residents and their families and friends can put their minds at ease. According to Medicare law, nursing home residents may leave their facility for family events without losing their Medicare coverage. However, depending on the length of their absence, beneficiaries may be charged a “bed hold” fee by their skilled nursing facility (SNF).

The Medicare Benefit Policy Manual recognizes that although most beneficiaries are unable to leave their facility,

an outside pass or short leave of absence for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride, or for a trial visit home, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care. [1]

The Manual elaborates: “Decisions in these cases should be based on information reflecting the care needed and received by the patient while in the SNF and on the arrangements needed for the provision, if any, of this care during any absences.” [2] However, a facility should NOT notify patients that leaving the facility will lead to loss of Medicare coverage. The Medicare Benefit Policy Manual says that such a notice is “not appropriate.” [3]

If the resident begins a leave of absence and returns to the facility by midnight of the same day, the facility can bill Medicare for the day’s stay. [4] If the resident is gone overnight (i.e., past midnight) and returns to the facility the next day, the day the resident leaves is considered a leave of absence day. Clarifying what seemed to be conflicting provisions in the Manuals, the Centers for Medicare & Medicaid Services (CMS) now confirms that the facility can bill a beneficiary for bed-hold days during a temporary SNF absence. [5]

Chapter 6 of the Medicare Claims Processing Manual provides that the facility cannot bill a beneficiary during a leave of absence, “except as provided in Chapter 1 of the manual at §30.1.1.1.” [6] As required by the federal Nursing Home Reform Law, [7] that section authorizes SNFs to bill a beneficiary for bed-hold during a temporary “SNF Absence” if the SNF informs the resident in advance of the option to make bed-hold payments and of the amount of the charge and if the resident “affirmatively elect[s]” to make bed-hold payments prior to being billed. [8]

The Manual states that a facility “cannot simply deem a resident to have opted to make such payments and then automatically bill for them upon the resident’s departure from the facility.”  [9] Charges to hold a bed and maintain the resident’s “personal effects in a particular living space that the resident has temporarily vacated… are calculated on the basis of a per diem bed-hold payment rate multiplied by however many days the resident is absent, as opposed to assessing the resident a fixed sum at the time of departure from the facility.” [10] CMS distinguishes bed-hold payments from payments for admission or readmission, which are “not allowable.” [11]

In summary, residents can leave their SNFs for short periods, such as a day or two, to enjoy gatherings with their families and friends without losing Medicare coverage. However, SNFs are allowed to bill residents to reserve their beds so long as they advised residents in advance of the charges to hold the bed and the residents have agreed, in advance, to make the payments.

Happy Holidays!

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[1] Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, second paragraph) (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf). Scroll down to page 43.
[2] Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, second paragraph) (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf). Scroll down to page 43.
[3] Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, third paragraph) (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf). Scroll down to page 44.
[4] Medicare Benefit Policy Manual, Pub. 100-02, Ch. 3, §20.1.2. (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c03.pdf). Scroll down to page 4.
[5] Medicare Claims Processing Manual, Pub. 100-04, Ch. 6, §40.3.5.2. (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf). Scroll down to page 51-52. Note, unlike Medicaid in some states, the Medicare program does not provide any payment for “bed-hold.”
[6] Medicare Claims Processing Manual, Pub. 100-04, Ch. 6, §40.3.5.2. (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf). Scroll down to page 51-52.
[7] 42 U.S.C. §1395i-3(c)(1)(B)(iii), 42 C.F.R. §483.10(f)(10).(11).
[8] Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §30.1.1.1 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf). Scroll down to page 48. CMS cites, as authority for this payment option, the Nursing Home Reform Law, 42 U.S.C. §1395i-3(c)(1)(B)(iii), and 42 C.F.R. §483.10(g)(17)-(18). [9] Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §30.1.1.1 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf). Scroll down to page 48.
[10] Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §30.1.1.1 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf), scroll down to page 48.
[11] Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §30.1.1.1 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf). Scroll down to page 48.

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Two Weeks Left in Medicare Enrollment Period

The current Medicare enrollment period ends on December 7, 2019. As reported yesterday in the Minneapolis Star Tribune, while some Medicare Plan Finder (MFP) problems previously identified have been fixed, there are still significant outstanding issues.  As noted in the article, “[i]n some cases, the federal website has been showing wrong information about drug formularies, […] In other cases, the information about premiums and out-of-pocket costs doesn’t match data the state agency receives directly from insurers.” According to a senior policy analyst at the Minnesota Board on Aging, “‘Our concern is that even though CMS is working on changes, all the changes haven’t been done yet and we’re concerned that people are making decisions and enrolling in plans that aren’t going to be the best for them in 2020.’”

CMS has reported that the 1-800-MEDICARE call center is no longer referring individuals to their State Health Insurance Assistance Programs (SHIPs) during the current enrollment period. Although 16 state SHIP programs to date have apparently informed CMS that they can no longer take such referrals due to their caseloads, referrals to all SHIP programs have stopped until the end of the current Medicare enrollment period. Concerns about SHIP caseloads are warranted, particularly given the challenges associated with counselors learning the new MPF and the functional problems it has presented, however SHIPs remain the best source of neutral, unbiased counseling on Medicare options, and limiting referrals to such programs that are still able to serve their state’s residents limits Medicare beneficiaries’ access to quality information.

Medicare messaging continues to be all about “plans” but not traditional Medicare. As discussed in a CMA Alert earlier this month, email messages from Medicare during the current enrollment period continue to focus only on “plans.” As noted, CMS should make clear that people with traditional Medicare can stay put if they wish, and people enrolled in MA can consider the option of returning to traditional Medicare. Instead, information coming from CMS focuses almost exclusively on “plans” and “plan choices” with little or no reference to traditional Medicare as an option. Further, references to “health” coverage and prescription drug coverage are lumped together in a manner that does not account for individuals who are happy in traditional Medicare but benefit from help selecting a stand-alone Part D plan, not just an MA plan that includes Part D (MA-PD).

An email sent by the Medicare program dated 11/15, entitled “Find a plan that works for you”, makes no distinctions between traditional Medicare and MA plans, and states:

“Cost, coverage, and benefits are all important when choosing a Medicare health or drug plan, but there are even more things to consider:

  • Is the pharmacy you use included in your drug plan’s network?
  • Have your prescription drug needs changed?
  • Do your preferred doctors accept Medicare?
  • Do you travel a lot, or spend part of the year in a different state?”

While the first two questions are relevant to Part D prescription drug coverage, regardless of whether someone has a stand-alone Part D plan or is in an MA-PD, the last two question are relevant only to MA plans (and the third question should ask whether preferred doctors are in the Medicare Advantage network rather than just accepting Medicare).

Similarly, in an email from CMS dated 11/21 entitled “Review your health & drug coverage today” there is no mention of traditional Medicare, and “health” coverage is lumped together with prescription drug coverage:

“Now is your chance to review your Medicare health and drug coverage and make sure it meets your needs. Even if your plan hasn’t changed, there could be another plan that works better for you. You may be able to save money on prescriptions or get new extra benefits.”

As noted in earlier CMA Alerts, in an attempt to provide more balanced information about the choices between traditional Medicare and MA, the Center for Medicare Advocacy, along with the National Committee to Preserve Social Security and Medicare, relaunched our Fully Informed Project to provide an array of objective materials about all Medicare options.

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Medicare Advantage Plans Impede Access to Care: A Case Study #2

Medicare’s annual open enrollment period (October 15 – December 7), is time for beneficiaries to take stock of their Medicare options for the upcoming calendar year – whether to choose traditional (real) Medicare or a private insurance Medicare Advantage (MA) plan.

The Center for Medicare Advocacy (the Center) has developed information, materials, and educational webinars to promote informed choice by beneficiaries. As the Center has discussed over the last few years, information about Medicare coverage options produced by the Medicare program is no longer neutral; instead, such information now actively promotes MA enrollment, and paints the MA program in the most favorable light, while downplaying its drawbacks. We have heard from a number of beneficiaries, advocates, and providers about their MA experiences. Last week we launched a series to highlight one of those first-hand reports, and to counter-balance MA industry advertising and Medicare program’s steering efforts. In today’s Alert, and upcoming CMA Alerts, we will write about other beneficiary, advocate, and provider experiences. These are all cautionary tales about Medicare Advantage that are not receiving adequate attention elsewhere.

We invite you to join this discussion by sending us your MA plan experiences to MedicareAdvantage@MedicareAdvocacy.org.

Case Study 2: Family History of Colon Cancer Should Increase the Frequency of Colonoscopies, but Ultimately the MA Plan, Not the Treating Doctor, May Determine When Procedures Will Occur[1]

Ms. McNeil has a family history of colon cancer that is well known to her doctors. Her mother’s father died of colon cancer at age 52, her father died of colon cancer at 76. Ms. McNeil and all of her siblings have had pre-cancerous polyps removed during each of multiple colonoscopies over the years. Because of a strong family history, and Ms. McNeil’s own personal medical history, her doctor has consistently recommended that Ms. McNeil should have a colonoscopy every 3 to 5 years.

Last year, Ms. McNeil joined an MA plan. When she had her scheduled colonoscopy this fall, her doctor told Ms. McNeil that the MA plan had notified him that it would only authorize a colonoscopy every 10 years, although the doctor recommended that she still have another colonoscopy in 3 to 5 years. Ms. McNeil also received a letter from the MA plan that coverage was for one colonoscopy every 10 years. Given this information, Ms. McNeil assumed that the benefit coverage in her MA plan limited her to a single colonoscopy every 10 years and she would have to pay out of pocket for her next colonoscopy (approximately $5,000).

If Ms. McNeil had been in traditional Medicare, she would have colonoscopies with the frequency that her doctor deems reasonable and necessary.  Colonoscopies are covered by Medicare as frequently as once every 24 months.[2] The doctor would document her family and personal history to justify the need for the testing and Medicare would cover the cost.

Ms. McNeil believed both her doctor and her private insurance MA plan when it told her that she could only be covered for one colonoscopy every 10 years, and she planned to accept it as “the way of things.” The Center, however, encouraged Ms. McNeil to challenge that decision as medically unacceptable. She knows it is her doctor’s professional opinion that she needs colonoscopies on a more frequent basis, and her doctor will support her request to the MA plan as medically reasonable and necessary. Her next colonoscopy should be covered; but will it?

The unfortunate truth is that MA plans have their own in-house doctors and medical case “utilization” reviewers who are allowed to override the decision of a patient’s treating doctors. Although MA plan doctors have never treated or examined Ms. McNeil, they may ultimately make a decision contrary to the recommendation of Ms. McNeil’s own doctors for the colonoscopy, or any other services, and deny coverage.

MA plans should not be allowed to override the expertise and opinion of treating providers at the expense of the patient’s health. MA plans should not be allowed to second guess providers through layers of in-house medical review as a vehicle to deny necessary care.


Next Case

Case #3: Wasting time waiting for prior authorization – at what physical and emotional cost?

Again, we invite you to join this discussion by sending us your MA plan experiences to MedicareAdvantage@MedicareAdvocacy.org.


[1] Factual recount as reported to CMA on November 2, 2019. The names of the beneficiaries, provider, and MA plans have been withheld for privacy purposes.
[2] See https://www.medicare.gov/coverage/screening-colonoscopies

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Issue Alert – Medicare Benefit Periods Under PDPM

Benefit Periods. Medicare covers up to a maximum of 100 days of skilled nursing facility (SNF/nursing home) care in each benefit period. A benefit period begins on the first day that a nursing home resident receives services and ends when the resident has not received inpatient hospital or nursing home services for at least 60 consecutive days. Residents may have multiple benefit periods in a single year but must meet all of the necessary Medicare coverage criteria (such as a three-day inpatient hospital stay) in order to start a new benefit period.

Note: Medicare Advantage plans may differ. Check with your plan for more information.

Multiple Stays in One Benefit Period. Nursing home residents may have their Medicare coverage terminated or may be discharged from the nursing home before using all allowable days in their benefit period. In such cases, residents may resume their benefit period if the nursing home (or a different nursing home) restarts skilled care or readmits the resident within 30 days of the termination or discharge date. A resident who has not received skilled care or has been discharged for more than 30 days, but less than 60 days, may resume a benefit period after a new three-day inpatient hospital stay.

Medicare Payment. On October 1, 2019, the Centers for Medicare & Medicaid Services (CMS) implemented a new payment model, the “Patient Driven Payment Model” (PDPM), for Medicare-covered nursing home care. The model has a declining per-day payment rate over the length of a resident’s stay. Thus, nursing homes are likely to receive less money for services on Day 21, for example, than on Day 1. In order to mitigate a nursing home’s incentive to discharge and readmit a resident to reset the payment rate, CMS has adopted an “Interrupted Stay” policy. According to CMS, an interrupted stay occurs when a beneficiary is “discharged from SNF care and subsequently readmitted to the same SNF (not a different SNF) within 3 days or less after the discharge…” In these cases, Medicare payment resumes from the day of discharge (e.g., Day 21).

PDPM’s Impact on Benefit Periods. PDPD should have no impact on a resident’s ability to resume his or her Medicare benefit period. The interrupted stay policy affects Medicare payment, not Medicare coverage. Any facility that blocks a resident from resuming a benefit period on the basis of the interrupted stay policy is applying the wrong standard.

Additional PDPM Resources:

  1. Issue Alert: Medicare Skilled Therapy under PDPM
  2. Fact Sheet: Nursing Home Therapy Services

 


 

For more information about Medicare and nursing home care, please visit: www.MedicareAdvocacy.org & www.NursingHome411.org.

 


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