CMS Pub. 100-04, ch. 6, § 90.1

If a beneficiary voluntarily or involuntarily dis-enrolls from a risk MA plan while an

inpatient of an SNF and converts to original Medicare (i.e., fee for service) the

requirement for a three day hospital stay will be waived if the beneficiary meets the level

of care criteria found in 42 CFR 409, Subpart D, up through the effective date of disenrollment. The beneficiary will then be eligible for the number of days that remain out

of the 100 day SNF benefit for that particular SNF stay minus those days that would have

been covered by the program under original Medicare while the beneficiary was enrolled

in the risk MA plan. However, in cases where the beneficiary disenrolls from a risk MA

plan after discharge from the SNF, and then is readmitted to the SNF under the 30 day

rule, all requirements for original Medicare (i.e., fee for service), including the 3-day

hospital stay must be met. Rules regarding cost sharing apply to these cases. That is,

providers may only charge beneficiaries for SNF coinsurance amounts.

If the beneficiary voluntarily disenrolls from a risk MA plan and converts to original

Medicare (i.e., fee for service) before admission to a SNF then the beneficiary must meet

all original Medicare requirements for a SNF stay, including that of a three day inpatient

hospital stay.

SNFs submit all applicable fee-for-service inpatient SNF claims with condition code “58”

to indicate a patient was disenrolled from an MA plan and the 3-day prior stay

requirement was not met. Claims with condition code 58 will not require the 3-day prior

inpatient hospital stay. The A/B MAC (A) must use CWF files to validate the beneficiary

was enrolled in an MA organization upon admission to the SNF and that the MA

enrollment period ended prior to the “from” date on the claim. The A/B MAC (A) does

not need to verify that the MA plan was the one that terminated.