CMS Pub. 100-04, ch. 1, § 90

for Only a Portion of the Billing Period

(Rev. 11731, Issued: 12-09-22, Effective: 01-11-23, Implementation: 01-11-23)

Where a patient either enrolls or disenrolls in an MA organization (See Pub. 100-01, the

General Information, Eligibility, and Entitlement Manual, Chapter 5, §80 for definition)

during a period of services, two factors determine whether the MA organization is liable

for the payment.

• Whether the provider is included in inpatient hospital or home health PPS, and

• The date of enrollment.

Hospital Services

If the provider is an inpatient acute care hospital, inpatient rehabilitation facility or a long

term care hospital, and the patient changes MA status during an inpatient stay for an

inpatient institution, the patient’s status at admission or start of care determines liability.

If the hospital inpatient was not an MA enrollee upon admission but enrolls before

discharge, the MA organization is not responsible for payment.

For hospitals exempt from PPS (children’s hospitals, cancer hospitals, CAHs and

Maryland waiver hospitals), if the MA organization has processing jurisdiction for the

MA involved portion of the bill, it will direct the provider to split the bill and send the

appropriate portions to the appropriate FI or MA organization. When forwarding a bill to

an MA organization, the provider must also submit the necessary supporting documents.

If the provider is not a PPS provider, the MA organization is responsible for payment for

services on and after the day of enrollment up through the day that disenrollment is

effective.

Home Health

If the patient was enrolled in the MA organization before start of care, the MA

organization is liable until disenrollment. Upon disenrollment, an episode must be opened

under home heath PPS for billing to the FI.

If the beneficiary was not an MA enrollee upon admission but enrolls before discharge,

the home health PPS episode will end as of the day before the MA enrollment. The

episode will be proportionately paid according to its shortened length (i.e., paid a partial

episode payment [PEP] adjustment). The MA organization is responsible for payment as

of the MA enrollment date.

91 - Moral and Religious Fee for Service Claims for Medicare

Beneficiaries Enrolled in Certain Medicare Advantage (MA) Plans