Administrative Level of Care Presumption

30.1 – Administrative Level of Care Presumption (Rev. 261, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19) Under the SNF PPS, beneficiaries who are admitted (or readmitted) directly to a SNF after a qualifying hospital stay are considered to meet the level of care requirements of 42 CFR 409.31 up to and including the assessment reference date (ARD) for the initial Medicare assessment prescribed in 42 CFR 413.343(b), when correctly assigned one of the case-mix classifiers that CMS designates for this purpose as representing the required level of care. While this assessment is commonly referred to as the “5-day” assessment (reflecting its original 5-day assessment window), an additional 3 grace days have always been available beyond that window for actually setting the ARD; further, as of October 1, 2019, those additional 3 grace days are directly incorporated into the assessment window itself, thus resulting in an overall 8-day assessment window. The current set of case-mix classifier designations appears in the paragraph entitled “Case Mix Adjustment” on the SNF PPS web site, at https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/SNFPPS/index.html. If the beneficiary is not admitted (or readmitted) directly to a SNF after a qualifying hospital stay, the administrative level of care presumption does not apply. For purposes of this presumption, the assessment reference date is defined in accordance with 42 CFR 483.315(d), and must be set for no later than the eighth day of posthospital SNF care. Consequently, if the ARD for the initial Medicare assessment prescribed in 42 CFR 413.343(b) is set for day 9, or later, the administrative level of care presumption does not apply. The coverage that arises from this presumption remains in effect only for as long thereafter as it continues to be supported by the facts of the beneficiary’s condition and care needs. Accordingly, the SNF is expected to monitor carefully for and document any changes in the patient’s condition, in order to determine the continuing need for Part A SNF benefits after the ARD. Moreover, this administrative presumption does not apply to any subsequent assessments. To be correctly assigned, the data coded on the Resident Assessment Instrument (RAI) must be accurate and meet the definitions described in the Long Term Care Facility RAI User’s Manual. The beneficiary must receive services in the SNF that are reasonable and necessary. Services provided to the beneficiary during the hospital stay are reviewed to ensure proper coding of the most recent version of the RAI. The two examples illustrated below demonstrate a correct assignment and an incorrect assignment. Incorrect Assignment: IV med provided in hospital coded on MDS, but IV was for a surgical procedure only – as a consequence, the MDS is not accurate and the presumption does not apply (see Chapter 3, Section P of the RAI). Correct Assignment: Beneficiary is receiving oxygen therapy as well as rehab service. The respiratory therapy services are found reasonable and necessary; however, the rehab services are found not reasonable and necessary, resulting in a revised case-mix classification. Beneficiary was and is now correctly assigned – presumption applies. A beneficiary who is not assigned one of the case-mix classifiers designated as representing the required level of care on the initial Medicare assessment prescribed in 42 CFR 413.343(b) is not automatically classified as meeting or not meeting the SNF level of care definition. Instead, the beneficiary must receive an individual level of care determination using existing administrative criteria and procedures. The following scenarios further clarify that a beneficiary’s correct assignment of one of the case-mix classifiers that CMS designates for this purpose as representing the required level of care would serve to trigger the coverage presumption under the initial Medicare assessment only when that assessment occurs directly following the beneficiary’s discharge from the qualifying hospital stay (i.e., the hospital discharge and subsequent SNF admission both occur on the same day). 1. Routine SNF Admission Directly From Qualifying Hospital Stay If the beneficiary is admitted to the SNF immediately following a 3-day qualifying hospital stay, there is a presumption that he or she meets the Medicare level of care criteria when correctly assigned one of the case-mix classifiers that CMS designates for this purpose as representing the required level of care. The presumption lasts through the assessment reference date of the initial Medicare assessment, which must be set for no later than the eighth day of the stay. 2. Admission to SNF does not immediately follow discharge from the qualifying hospital stay, but occurs within 30 days (as required under the “30 day transfer” rule) If the beneficiary is discharged from the hospital to a setting other than the SNF, the presumption of coverage does not apply, even if the beneficiary’s SNF admission occurs within 30 days of discharge from the qualifying hospital stay. Accordingly, coverage would be determined based on a review of the medical evidence in the file. 3. SNF Resident is Re-Hospitalized and Then Returns Directly to the SNF If a beneficiary who has been in a covered Part A stay requires readmission to a hospital, and subsequently returns directly to the SNF for continuing care, a new initial Medicare assessment under the regulations at 42 CFR 413.343(b) would be required if the beneficiary’s absence from the SNF exceeds the 3-day interruption window specified under the SNF PPS’s interrupted stay policy (see Pub. 100-04, Medicare Claims Processing Manual, Chapter 6, §120.2). In this scenario, there is a presumption that he or she meets the level of care criteria upon direct readmission from the hospital to the SNF when correctly assigned one of the case-mix classifiers that CMS designates for this purpose as representing the required level of care. The resulting presumption of coverage lasts through the assessment reference date (ARD) of that assessment, which must be set for no later than the eighth day of the stay. Alternatively, if the absence from the SNF does not exceed the 3-day interruption window, the beneficiary’s return to the same SNF would represent a continuation of the previous SNF stay; as such, there would be no new initial Medicare assessment and no new presumption of coverage; however, any days remaining from the previous presumption would continue to apply through the ARD of the original assessment. 4. Routine SNF Admission Directly From Qualifying Hospital Stay, but Initial Portion of SNF Stay Covered by Another Insurer (Medicare as Secondary Payer) When a beneficiary goes directly from a qualifying hospital stay to the SNF, but the initial portion of the SNF stay is covered by another insurer that is primary to Medicare, Medicare coverage would not start until coverage by the primary insurer ends. Accordingly, the Medicare required assessment schedule would not begin until the first day of Medicare coverage. If a beneficiary met the level of care criteria for Medicare coverage during the first 8 days of the stay following a qualifying hospital stay, and the other insurer covered this part of the stay, there is no presumption. If Medicare becomes primary before the eighth day of the stay following a qualifying hospital stay, the presumption would apply through the assessment reference date on the initial Medicare assessment or, if earlier, the eighth day of the stay. 5. Readmission to SNF Within 30 Days After Discharge From Initial SNF Stay – No Intervening Hospitalization As noted in scenario 1, if a beneficiary is initially admitted to the SNF directly from the qualifying hospital stay for a covered Part A SNF stay, the presumption for that stay is applicable when the beneficiary is correctly assigned one of the case-mix classifiers that CMS designates for this purpose as representing the required level of care. However, if that beneficiary is discharged to a non-hospital setting and then subsequently readmitted to the SNF beyond the 3-day interruption window as described in scenario 3 above, there is no presumption applicable to the second SNF admission. (If the beneficiary is transferred to a hospital, and returns directly to the SNF, see scenario 3 above). Alternatively, if the absence from the SNF does not exceed the 3-day interruption window, the beneficiary’s return to the same SNF would represent a continuation of the previous SNF stay; as such, any days remaining from the previous presumption would continue to apply through the ARD of the original assessment. 6. Initial, Non-Medicare SNF Stay Followed by Qualifying Hospitalization and Readmission to SNF for Medicare Stay Dually eligible (Medicare/Medicaid) beneficiaries whose initial stay in the SNF is either Medicaid-covered or private pay, are eligible for the Medicare presumption of coverage when readmitted directly to the SNF following a qualifying hospitalization, when correctly assigned one of the case-mix classifiers that CMS designates for this purpose as representing the required level of care. (Of course, in order to qualify for Medicare coverage upon readmission, the beneficiary must be placed in the portion of the institution that is actually certified by Medicare as a SNF.) No presumption of coverage applies when Medicare is the secondary payer for days 1 through 8 of the covered stay where Medicare becomes primary after day 8 due to a reversal or denial by the secondary insurer. 7. Transfer From One SNF to Another There is no presumption of coverage in cases involving the transfer of a beneficiary from one SNF to another or from SNF-level care in a hospital swing bed to a SNF. The presumption only applies to the SNF stay that immediately follows the qualifying hospital stay when the beneficiary is correctly assigned one of the case-mix classifiers that CMS designates for this purpose as representing the required level of care. Therefore, in cases involving transfer of a beneficiary from a swing-bed hospital to a SNF, the presumption only applies if the beneficiary was receiving acute care (rather than SNF-level care) immediately prior to discharge from the swing-bed hospital.