Prior Hospitalization and Transfer Requirements for SNF

130.2 - Prior Hospitalization and Transfer Requirements for SNF Coverage as Related to Limitation on Liability (Rev. 1, 10-01-03) In order to qualify for post-hospital extended care services, the individual must meet the prior hospitalization and transfer requirements discussed in “Coverage of Extended Care Services Under Hospital Insurance,” Chapter 8 of the Medicare Benefit Policy Manual. The following sections discuss the relationship of these requirements to the limitation on liability provision. A. Three-Day Prior Hospitalization Before Medicare can pay for post-hospital extended care services, it must determine whether the beneficiary had a prior qualifying hospital stay of at least three consecutive calendar days. When a beneficiary’s liability for a hospital stay is waived, the hospital days to which the limitation on liability applies cannot be used to satisfy the 3-day prior hospitalization requirement, since the services rendered during the days in question were found noncovered because they were not considered reasonable and necessary or because they constituted custodial care. (See “Coverage of Extended Care (SNF) Services Under Hospital Insurance,” Chapter 8, of the Medicare Benefit Policy Manual for determining whether the 3-day prior hospitalization requirement is met.) If a beneficiary’s hospital stay was partially covered, the A/B MAC (A) considers the covered portion of the stay in determining whether the SNF prior hospitalization requirement is met. B. Transfer Requirements 1. Transfer Period The A/B MAC (A) applies the limitation on liability provision where it determines that all the SNF care received during the period serving to satisfy the transfer requirements described in “Coverage of Extended Care Services Under Hospital Insurance,” Chapter 8 of the Medicare Benefit Policy Manual, either constituted custodial care or was not reasonable and necessary. Where the A/B MAC (A) determines that only the beneficiary’s liability can be waived, the limitation on liability applies through the date of the notice to the beneficiary including any inpatient days beyond the transfer period. If the provider is also entitled to limitation on liability and program payment is possible under the limitation on liability provision, such payment is appropriate through the date of the notice and, if the A/B MAC (A) determines that additional time is needed to arrange for post-discharge care, for up to 24 hours after the date of notice to the provider or the beneficiary, whichever is earlier. If the A/B MAC (A) determines that even more time is needed to arrange post-discharge care, up to 24 additional hours may be paid for. (See §50.) Where a beneficiary who is entitled to limitation on liability starts to require and receives reasonable and necessary or noncustodial services only after the expiration of the SNF transfer period, the beneficiary nevertheless may have his/her liability waived for days where such services were rendered, in addition to those days waived during the noncovered transfer period but only through the date of notice to the beneficiary. If the provider is also entitled to limitation on liability, program payment may be made under the limitation on liability provision through the date of notice of noncoverage and, if the A/B MAC (A) determines that additional time is needed to arrange for post-discharge care, for a “grace period” of l day thereafter. If the A/B MAC (A) determines that even more time is needed to arrange post-discharge care, 1 additional “grace period” day may be paid for. (See §50.) This payment is made because it is inequitable to waive liability for noncovered services rendered during the transfer period but not for a period thereafter (prior to notice) during which the beneficiary needed and received an otherwise covered level of care. 2. Delayed Transfer Due to Medical Appropriateness The law also provides for an extension of the usual 30-day time limit for transfer where the patient’s condition makes it medically appropriate. (“Coverage of Extended Care Services Under Hospital Insurance,” in the Medicare Benefit Policy Manual, Chapter 8.) However, if the A/B MAC (A) determines that such an extension is not allowable because an interval of more than 30 days for transfer to a SNF was not medically appropriate, it denies the SNF services because the transfer requirement was not met. The limitation on liability provision is not applicable in such a case.