CMS Pub. 100-02, ch. 8, § 30.7.3

Utilization of an Available, More Economical Care Alternative

(Rev. 1, 10-01-03)

A3-3132.6.C, SNF-214.6.C

In determining the practicality of using more economical care alternatives, the A/B MAC

(A) considers the patient’s medical condition. If the use of those alternatives would

adversely affect the patient’s medical condition, the A/B MAC (A) concludes that as a

practical matter the daily skilled services can only be provided by a SNF on an inpatient

basis.

If the use of a care alternative involves transportation of the individual on a daily basis,

the A/B MAC (A) considers whether daily transportation would cause excessive physical

hardship. Determinations on whether a patient’s condition would be adversely affected if

an available, more economical care alternative were utilized should not be based solely

on the fact that the patient is nonambulatory. There are individuals confined to

wheelchairs who, though nonambulatory, could be transported daily by automobile from

their homes to alternative care sources without any adverse impact. Conversely, there are

instances where an individual’s condition would be adversely affected by daily

transportation to a care facility, even though the individual is able to ambulate to some

extent.

EXAMPLE: A 75-year-old woman has suffered a cerebrovascular accident and cannot

climb stairs safely. The patient lives alone in a second-floor apartment accessible only by

climbing a flight of stairs. She requires physical therapy and occupational therapy on

alternate days, and they are available in a CORF one mile away from her apartment.

However, because of her inability to negotiate the stairs, the daily skilled services she

requires cannot, as a practical matter, be provided to the patient outside the SNF.

The “practical matter” criterion should never be interpreted so strictly that it results in the

automatic denial of coverage for patients who have been meeting all of the SNF level of

care requirements, but who have occasion to be away from the SNF for a brief period of

time. While most beneficiaries requiring a SNF level of care find that they are unable to

leave the facility, the fact that a patient is granted an outside pass or short leave of

absence for the purpose of attending a special religious service, holiday meal, family

occasion, going on a car ride, or for a trial visit home, is not, by itself evidence that the

individual no longer needs to be in a SNF for the receipt of required skilled care. Where

frequent or prolonged periods away from the SNF become possible, the A/B MAC (A)

may question whether the patient’s care can, as a practical matter, only be furnished on

an inpatient basis in a SNF. Decisions in these cases should be based on information

reflecting the care needed and received by the patient while in the SNF and on the

arrangements needed for the provision, if any, of this care during any absences. (See the

Medicare Benefit Policy Manual, Chapter 3, “Duration of Covered Inpatient Services,”

§20.1.2, for counting inpatient days during a leave of absence.)

A conservative approach to retain the presumption for limitation of liability may lead a

facility to notify patients that leaving the facility will result in denial of coverage. Such a

notice is not appropriate. If a SNF determines that covered care is no longer needed, the

situation does not change whether the patient actually leaves the facility or not.