Application of Medicare/Medicaid Requirements to Private Pay

2714.1 - Application of Medicare/Medicaid Requirements to Private Pay Patients (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) The CoPs/Requirements apply to the entire certified provider/supplier and to all patients/residents being served by the certified entity, regardless of payment source unless stated otherwise in the regulations. This means that the surveyors may review the care of private pay patients/residents when surveying a Medicare/Medicaid approved provider or supplier. This policy is based on the premise that it is the provider or supplier that is being approved, not just the beds of or care provided to Medicare/Medicaid beneficiaries. Of course, this policy does not apply to patients/residents residing in non-certified portions of facilities (e.g., the non-certified portions of SNFs which have only a portion of their beds Medicare-certified as a distinct part SNF; or the non-certified buildings on the campus of large institutions such as psychiatric hospitals or ICFs/IID). (See §§2048 and 7016.) In some cases it may not be immediately clear whether a division of the certified provider/supplier is covered by the certification. For example, an HHA may have a separate division in the organization that provides personal care attendant or homemaker services or that provides services to private pay patients. Unless the agency can demonstrate that the separate division is operated as a separate entity, the CoPs apply to all home health services provided by the entire HHA. If the SA cannot make a clear determination, it should consult the RO. Also, certain provisions of the CoPs/Requirements specifically address patients of certain payment sources. For example, the CoPs for providers of OPT/OSP services contain certain requirements that apply only to Medicare patients. (See 42 CFR 486.155(b)(4).) SNF/NF requirements in 42 CFR 483.12(d)(3)(i) state, “A nursing facility may charge a resident who is eligible for Medicaid...” However, when the CoPs/Requirements refer to patients, residents, clients, or individuals in general terms and do not specifically limit the requirement to Medicare or Medicaid, those regulations apply to all persons served by the certified provider/supplier.