CMS Pub. 100-01, ch. 3, § 10.4.4

Generally, a beneficiary is an inpatient of a hospital if the beneficiary is receiving

inpatient services in the hospital (i.e., not on an outpatient basis). The type of care

actually received is not relevant.

However, a different definition of inpatient applies in determining the end of a benefit

period for a beneficiary in a SNF, under which such a beneficiary is considered an

inpatient in this context only if the beneficiary's care in the SNF meets certain skilled

level of care standards. Specifically, the beneficiary must need and receive a skilled level

of care while in the SNF.

This means that in order to have been an “inpatient” for benefit period purposes while in

a SNF, the beneficiary must have required and received skilled services on a daily basis

which could, as a practical matter, only have been provided in a SNF on an inpatient

basis. (Under the regulations at 42 CFR 409.60(b)(2), an additional level of care criterion

at 42 CFR 409.31(b)(2)--requiring that the SNF care must in some way relate back to a

condition that was present during the beneficiary’s qualifying hospital stay--does not

apply to benefit period determinations.) If these provisions were not met during the prior

SNF stay, the beneficiary was not an inpatient of the SNF for purposes of prolonging the

benefit period. Conversely, a beneficiary would remain an SNF “inpatient” in this

context (thus prolonging his or her current benefit period) for as long as the beneficiary

continues receiving a skilled level of care in the SNF--even if Part A payment has ended

due to the beneficiary’s exhaustion of SNF benefits.

Use the following presumptions for determining whether the skilled level of care

standards were met during a prior SNF stay.

Presumption 1: A beneficiary's care in a SNF met the skilled level of care standards if a

Medicare SNF claim was paid for the care, unless such payment was made under

limitation on liability rules.

Presumption 2: A beneficiary's care in a SNF met the skilled level of care standards if a

SNF claim was paid for the services provided in the SNF under the special Medicare

limitation on liability rules pursuant to placement in a non-certified bed.

Presumption 3: A beneficiary's care in a SNF did not meet the skilled level of care

standards if a claim was paid for the services provided in the SNF pursuant to the general

Medicare limitation on liability rules. (This presumption does not apply to placement in

a non-certified bed. For claims paid under these special provisions, see Presumption 2.)

Presumption 4: A beneficiary's care in a Medicaid nursing facility (NF) did not meet the

skilled level of care standards if a Medicaid claim for the services provided in the NF was

denied on the grounds that the services received were not at the NF level of care (even if

paid under applicable Medicaid administratively necessary days provisions which result

in payment for care not meeting the NF level of care requirements).

Presumption 5: A beneficiary's care in a SNF met the skilled level of care standards if a

Medicare SNF claim for the services provided in the SNF was denied on grounds other

than that the services were not at the skilled level of care.

Presumption 6: A beneficiary's care in a SNF did not meet the skilled level of care

standards if a Medicare claim for the services provided in the SNF was denied on the

grounds that the services were not at the skilled level of care and no limitation of liability

payment was made.

Presumption 7: A beneficiary's care in a SNF did not meet the skilled level of care

standards if no Medicare or Medicaid claim was submitted by the SNF.

Presumptions 1 through 4 cannot be rebutted. Thus, prior Medicare and Medicaid claim

determinations that necessarily required a level of care determination for the time period

under consideration are binding for purposes of a later benefit period calculation.

Presumptions 5 through 7 can be rebutted by the beneficiary showing that the level of

care needed or received is other than that which the presumption dictates.

Presumption 6 can be rebutted because the Medicare skilled level of care definition for

coverage purposes is broader than the skilled level of care definition used here for benefit

period determinations. Specifically, the requirement referred to in Chapter 4, §40.2

regarding prior hospital care related to the SNF care is included in the Medicare SNF

coverage requirements but is not included in the standard for benefit period

determinations. Therefore, Medicare payment could have been denied for a SNF stay on

level of care grounds (i.e., not even waiver payment was made) because of

noncompliance with that requirement, even though skilled level of care requirements for

benefit period determinations were in fact met by the SNF stay. Consequently, when

Medicare SNF payment is denied on level of care grounds, the beneficiary must be given

the opportunity to demonstrate that he/she still needed and received a skilled level of care

for purposes of benefit period determinations.

NOTE: Effective October 1, 1990, the levels of care that were previously covered

separately under the Medicaid SNF and intermediate care facility (ICF) benefits are

combined in a single Medicaid nursing facility (NF) benefit. Thus, the Medicaid NF

benefit includes essentially the same type of skilled care covered by Medicare's SNF

benefit, but it includes less intensive care as well. This means that when a person is

found not to require at least a Medicaid NF level of care (as under Presumption 4), it can

be presumed that he or she also does not meet the Medicare skilled level of care

standards. However, since the NF benefit can include care that is less intensive than

Medicare SNF care, merely establishing that a person does require NF level care does not

necessarily mean that he or she also meets the Medicare skilled level of care standards.

Determining whether an individual who requires NF level care also meets the Medicare

skilled level of care standards requires an actual examination of the medical evidence and

cannot be accomplished through the simple use of a presumption. Therefore, the

previous references to Medicaid claims have been deleted from those presumptions

which establish that an individual does meet the Medicare standards.

Medicare no-payment bills submitted by a SNF result in Medicare program payment

determinations (i.e., denials). Therefore, such no-payment bills trigger the appropriate

presumptions. This also applies in any State where the Medicaid program utilizes no-payment bills which lead to Medicaid program payment determinations. If a SNF

erroneously fails to submit a Medicare claim (albeit a no-pay claim) when Medicare rules

require such submission, A/B MACs (A) request a SNF to submit one. Once the no-pay

bill is submitted and denied, the applicable presumption (other than presumption 7) is

triggered. If a patient is moving from a SNF level of care to a non-SNF level of care in a

facility certified to provide SNF care, occurrence code 22 (date active care ended) is used

to signify the beginning of the no-pay period on the bill and trigger the appropriate

presumptions.

Where the presumptions are rebuttable (i.e., 5 through 7), rebuttal showings are permitted

at both A/B MAC (A) determination levels under 42 CFR 405, Subpart G (i.e., a rebuttal

showing regarding the status of a prior SNF stay is made at the time that an inpatient

claim is submitted and/or at the reconsideration level). A/B MACs (A) evaluate rebuttal

documentation even if the presumption being rebutted was triggered by a Medicaid

denial.

This special rule for determining whether a beneficiary in a SNF is an inpatient for

benefit period purposes is applicable in all cases where a prior SNF stay affects benefit

period status, not only when a beneficiary is in exhausted or copay status and is seeking

to renew a benefit period. The rule has equal application where it results in the

beneficiary starting a new benefit period and paying a new deductible without receiving

an increase in the amount of Medicare benefits paid.