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Last Modified: 11/4/2020 Location: FL, PR, USVI Business: Part A

COVID-19: Skilled nursing facility (SNF) waiver to extend the benefit period

On March 13, 2020, the Centers for Medicare & Medicaid (CMS) issued a Skilled Nursing Facility (SNF) waiver under 1812(f) of the Social Security Act (the Act) based on the Public Health Emergency (PHE) declared by the Secretary under 319 of the Public Health Service Act, which is effective with respect to the timeframes and geographic areas specified in the waiver(s) issued under section 1135 of the Act in response to the COVID-19 PHE. By issuing this waiver, CMS recognized that the disruptions arising from a PHE can impede the normal operation of the SNF benefit, by preventing a beneficiary from having the qualifying hospital stay (QHS) that otherwise would have occurred. Similarly, the PHE can also disrupt the normal process of ending the beneficiary’s current benefit period and beginning their new SNF benefit period.
For the QHS waiver, the beneficiary’s status of being “affected by the emergency” is simply assumed to exist nationwide under the current PHE, and need not be verified in an individual case. However, for the benefit period waiver, there is one particular scenario that requires establishing an actual connection to the emergency: that is, when the beneficiary is receiving ongoing skilled care in the SNF. Under normal circumstances, this scenario would have the effect of prolonging a beneficiary’s current benefit period and precluding the renewal of SNF benefits.
Accordingly, to qualify for the benefit period waiver, it must be demonstrated that such a beneficiary’s continued receipt of skilled care in the SNF is in some way related to the emergency itself. One example would be when a beneficiary who had been receiving daily skilled therapy prior to the emergency then develops COVID-19 and requires a respirator and a feeding tube. However, even beneficiaries who do not themselves have a COVID-19 diagnosis may nevertheless be affected by the COVID-19 outbreak, as when disruptions from the emergency cause delays in obtaining treatment for another condition.
This means that during the PHE, all SNF beneficiaries (including those with SNF benefit days remaining in their current benefit period) would qualify for the QHS waiver. Those beneficiaries who have exhausted their current SNF benefit days generally would qualify for the benefit period waiver as well, except for beneficiaries who are receiving ongoing skilled care in the SNF that is unrelated to the emergency.
The following guidance provides specific instructions for utilizing the QHS and benefit period waivers, as well as the impacts on claims processing and SNF patient assessments:
For a beneficiary who has SNF benefit days remaining, enter a DR (“disaster related”) condition code on the claim for an emergency waiver of the QHS requirement.
For a beneficiary who has exhausted their 100 days of SNF benefits, the DR condition code will normally serve to indicate both a QHS waiver and a benefit period waiver. However, if there is a no-pay bill present for the same beneficiary (indicating the continuing receipt of skilled care in the SNF), the Medicare Administrative Contractor (MAC) presumes that the beneficiary’s ongoing skilled care is unrelated to the emergency and, therefore, the benefit period waiver does not apply in this particular case. Where applicable, SNF providers should include additional documentation to rebut this presumption by establishing that the ongoing skilled care being furnished during the PHE actually is related to the COVID-19 outbreak, as discussed above. SNF providers will need to make the determination that the waiver applies. The medical records should also clearly document that the care being furnished meets the waiver requirements. In order to make use of the benefit period waiver, providers must discharge the patient on the 100th day of the patient’s current benefit period. Discharging the patient requires that the provider complete a Prospective Payment System (PPS) Discharge Assessment, setting the 100th day of the patient’s current benefit period as the Assessment Reference Date (ARD) for this assessment. As the patient is not leaving the building, an Omnibus Budget Reconciliation Act of 1987 (OBRA) discharge assessment is not required.
The patient would then be readmitted to the SNF the following day (day 101) as if it is the first day of a new benefit period and the first day of a new PPS stay. Admitting the patient requires that the provider complete a 5-day PPS Assessment. When the patient is discharged and then readmitted the following day pursuant to utilizing the benefit period waiver, the interrupted stay policy does not apply. The Health Insurance Prospective Payment System (HIPPS) code derived from this 5-day assessment should be used to bill for services furnished the patient during the stay that begins in the new benefit period. The variable per diem schedule would begin from Day 1 for this new stay and new benefit period.
Providers are asked to work with their respective MACs to provide the proper documentation indicating that the COVID-19 emergency applies for the benefit period waiver for each benefit period waiver claim. Additionally, we also recognize that during the COVID-19 PHE some SNF providers may have not submitted the PPS assessments as outlined above for the benefit period waiver. In these limited circumstances, providers may utilize the HIPPS code that was being billed when the beneficiary reached the end of their SNF benefit period.
The burden is on the provider to make the determination that the waiver applies. The medical records should clearly document that the care being furnished meets the waiver requirements and will be subject to post pay review.
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