Public health emergency billing guidance for skilled nursing facilities (SNFs)
Medicare natural disaster, man-made incident, or public health emergency (PHE) waivers
CMS allows programmatic waivers for impacted states under Section 1135 of the Social Security Act (SSA) when:
- The president declares a state of emergency, and
- Department of Health & Human Services (HHS) declares a public health emergency (PHE)
Information regarding current emergencies and the SSA waivers is available at CMS’ Emergency response webpage.
Billing SNF services during a PHE
Section 1812(f) of the SSA grants the Secretary the authority to waive the three-day qualifying hospital stay during an ongoing emergency (see qualifying waiver conditions above). Skilled Nursing Facility (SNF) providers may submit condition code “DR” (disaster-related) on applicable inpatient stay claims to request waiver of the three-day qualifying stay for beneficiaries who may not qualify.
Section 1812(f) of the SSA also allows for extended care services during a qualifying emergency. If a beneficiary exhausts 100 days of SNF benefits and was in the process of establishing a 60-day wellness period, the beneficiary may be entitled to an additional 100 SNF days benefit period under the section 1812(f) waiver.
When SNF benefits have exhausted before a new benefit period
The §1812(f) waiver is intended to provide additional benefits for a beneficiary who had exhausted the 100 days of SNF benefits available in the current benefit period and was in the process of establishing a new benefit period. A new benefit period is established after a period of 60 consecutive days’ elapses during which the beneficiary is not receiving skilled care in a SNF or inpatient hospital care. If the beneficiary at the time of a disaster or emergency situation is still receiving skilled care in the SNF after exhausting the 100 days of SNF benefits, he or she would not be in the process of establishing a new benefit period at that point and, consequently, would not qualify for additional coverage under the § 1812(f) waiver.
For additional information, please reference questions T-7 and T-11 of the Emergency-Related Policies and Procedures That May Be Implemented Without § 1135 Waivers to determine eligibility under this waiver.
For this situation, the SNF provider may:
- Request the additional benefits for an eligible beneficiary by billing condition code “DR” and submitting their claim.
- Contact customer service for additional assistance after the claim finalizes.