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Emergency Preparedness >> Memorandum
To: AHCA Members in Minnesota and North Dakota
From: Janice Zalen, Sr. Director of Special Programs
Subject: Relaxation of Certain Medicare Payment Rules in Response to the Flood Emergencies in Minnesota and North Dakota
Date: 3/30/2009
The declaration of a public health emergency in the states of Minnesota and North Dakota allowed the Centers for Medicare and Medicaid Services (CMS) to waive certain Medicare requirements to assure that emergency health needs are met.  CMS issued waivers under its section 1135 authority, which apply to all providers; and under section 1812(f), which is applicable only to skilled nursing facilities (SNFs).  In short, the 1812(f) waiver allows nursing facility admission without the 3-day hospital stay and also waives the spell of illness requirement for evacuees and others affected by the flooding who need skilled nursing facility care. 

Detailed information on the waivers as it relates to Medicare payment is available on the CMS web site. The information is in the form of frequently asked questions and answers (FAQs), with questions specific to skilled nursing facilities beginning on the bottom of page 10.  Highlights include the following:  

  • 3-day hospital stay waived: The 3-day qualifying hospital stay requirement is temporarily waived for beneficiaries impacted by the emergency. Thus beneficiaries who are discharged from a hospital early to make room for more seriously ill patients will be eligible for Medicare Part A SNF benefits as will beneficiaries who had not been in a hospital or SNF prior to being evacuated, but who now need skilled nursing care.
  • No formal discharge necessary if transfer if under 30 days: When a SNF evacuates patients to another SNF or hospital as part of an emergency plan, the initial SNF can transfer the patients to another facility “under arrangements” if the transfer is for less than 30 days. The transferring SNF need not issue a formal discharge in this situation, as it is still considered the provider and should bill Medicare for each day of care. The SNF is then responsible for reimbursing the receiving facility.
  • New spell of illness benefit period for discharged residents: A new SNF Part A benefit period will be available to any beneficiary recently discharged from a SNF who has not had the time to establish a new benefit period and has experienced trauma through dislocation or evacuation in connection with this emergency, regardless of the location of the receiving SNF. Therefore, in this situation, the admitting SNF does not need to be located in the emergency area. Part A coverage will be available as long as the beneficiary requires skilled care, up to 100 days. Full coverage will be available for the first 20 days. The daily Medicare coinsurance will be applied from days 21-100.
  • No new spell of illness benefit period for evacuated residents: If a resident previously exhausted the 100 day benefit period, remained at a skilled level of care, (status code 30 no code 22), was not discharged but was evacuated for a few days and now is back in the facility still requiring skilled care, that Medicare beneficiary does NOT receive additional days..
  • Patient status codes for claims: Those providers that transferred residents and are aware of the location of their former resident’s transfer should include the correct patient status code for the transfer (i.e., patient status code “03” = transfer to SNF). If not aware of the exact transfer, providers should use patient status code “01” (discharged to home or self care) in order to bypass any potential overlapping claim situations. Providers should include “Emergency” on their remarks page prior to submitting the claim to Medicare.
  • Payment to receiving providers: Receiving providers should make sure they include remarks indicating “Emergency” on any claims affected by this emergency.
  • Beneficiaries classified for rehabilitation, but facility unable to provide therapy services: When the facility is no longer able to provide therapy services as a result of the dislocations associated with the emergency, the RUG-III category stays in place for the Minimum Data Set (MDS) coverage period (e.g., the 5-day assessment can be used to bill from Day 1 up through Day 14, etc.) as long as the MDS was coded accurately. Payment will continue to be made at the assigned rehabilitation RUG level until the end of the covered time frame or until an Other Medicare-required assessment (OMRA) is completed. The OMRA must be completed 8 – 10 days after all therapies have been discontinued.
  • Medicare patients needing a SNF level of care in NF-only or non-certified beds: A SNF may expand its inpatient bed capacity by obtaining a waiver from CMS and placing hospital beneficiaries needing a SNF level of care in an NF-only or non-certified bed.

In addition, CMS’ Survey and Certification Group (S&C) previously developed S&C Public Health Emergency - All Hazards Frequently Asked Questions” (FAQs). These FAQs are posted on the S&C Emergency Preparedness Web site, under the resources page.  These FAQs provide a wealth of information on waiver requirements, survey issues, enforcement questions and billing issues.  The American Health Care Association will provide a memo summarizing those FAQs in a day or so.