CMS Pub. 100-02, ch. 8, § 30.7

A3-3132.6, SNF-214.6

In determining whether the daily skilled care needed by an individual can, as a “practical

matter,” only be provided in a SNF on an inpatient basis, the A/B MAC (A) considers the

individual’s physical condition and the availability and feasibility of using more

economical alternative facilities or services.

As a “practical matter,” daily skilled services can be provided only in a SNF if they are

not available on an outpatient basis in the area in which the individual resides or

transportation to the closest facility would be:

• An excessive physical hardship;

• Less economical; or

• Less efficient or effective than an inpatient institutional setting.

The availability of capable and willing family or the feasibility of obtaining other

assistance for the patient at home should be considered. Even though needed daily

skilled services might be available on an outpatient or home care basis, as a practical

matter, the care can be furnished only in the SNF if home care would be ineffective

because the patient would have insufficient assistance at home to reside there safely.

EXAMPLE: A patient undergoing skilled physical therapy can walk only with

supervision but has a reasonable potential to learn to walk independently with further

training. Further daily skilled therapy is available on an outpatient or home care basis,

but the patient would be at risk for further injury from falling, because sufficient

supervision and assistance could not be arranged for the patient in his home. In these

circumstances, the physical therapy services as a practical matter can be provided

effectively only in the inpatient setting.