8180 Special Topics Related to Long Term Care

8181 Treatment of Medicare Days - Medicare provides coverage for up to 100 days a year for skilled nursing facility care. During the first 20 days, the full cost of care is covered. Beginning with the 21st day, the individual has a co-payment obligation. Oftentimes the Medicare coverage is triggered when the person is going directly from a hospital to a nursing facility.

Financial eligibility shall continue to be determined based on the provisions of 8172 during the Medicare coverage period allowing for the full cost of the nursing facility care even though a portion or all of that cost is being covered by Medicare. Thus, for example, if the individual's patient liability is less than the DCF approved rate per 8172 (2), he or she is eligible regardless of whether Medicare benefits are being provided and the nursing facility is subject to the applicable DCF rate in regards to what, if anything, can be billed to DCF and/or the client during this time.

For clients whose liability is less than the DCF approved rate per 8172 (2), if the Medicare payment made exceeds the applicable DCF rate for the facility in a month, no further payment is due the home from either the client or the agency. However, there may be instances in which the Medicare payment may fall short of the DCF rate. Where this occurs, the client and/or agency will likely be responsible for payment depending on whether the individual is QMB eligible or not. This is because the amount of the client's co-insurance is an allowable expense for liability and payment purposes.

In these instances if the individual is QMB eligible, the Medicare payment to the facility and any additional DCF payment, where the Medicare payment does not exceed the DCF rate, is considered payment in full and the individual has no further payment responsibility. This is because the QMB program is responsible for payment of all Medicare co-insurance charges, including the nursing facility related charges. For all other individuals, the facility will get paid only at the DCF rate either through the client's liability or a combination of the liability and any agency payment.

As the amount of Medicare payment can never be adequately projected for a month, the Medicare period should be treated as though an DCF payment will be made. A patient liability should be calculated and transmitted via the LOTC screen for both QMB and non-QMB clients and a notice to the nursing facility. Since the first 20 days of the Medicare period may also not be accurately assessed, particularly if some of these days had been previously used, the patient liability and payment effective dates should correspond to the date the client enters the facility rather than delaying to the 21st day. For all intents and purposes, the case should appear as if there were no Medicare days involved. It would then be the responsibility of the nursing facility to correctly bill for these days.

For QMB clients, both the individual and nursing facility must be notified that there is no obligation during the Medicare coverage period. For non-QMB clients in notifying the individual of his or her liability during the Medicare period, it should be noted that only a portion of the liability may be due to the home or possibly none of the amount dependent upon how much Medicare pays for the client's care that month. If the Medicare payment is greater than what DCF would pay, the client would owe nothing further to the home. If it is less, the client would be responsible for the difference up to the liability amount. This same notation should appear on the notice to the nursing facility so that they are aware of the limitation.

It should be noted that where the client does not end up paying any liability because of QMB coverage or the amount of Medicare payment, the possibility of excess resources may occur. Both the client and/or family should be made aware of this possibility so that ineligibility does not result.