Adult Medicaid Manual MA-2270 LONG TERM CARE NEED AND BUDGETING

XIV. MEDICARE COVERAGE

From time to time the IMC may need to know information about Medicare benefits. The material below explains some of the Medicare benefits.

REISSUED 11/01/11 – CHANGE NOTICE 17-11

(XIV.)

A. Approved Medicare SNF Care In A Nursing Facility

1. Medicare Part A may cover nursing home costs for a limited period of time if the care meets Medicare SNF requirements. Contact the facility to confirm Part A coverage.

a. There is no co-payment for the first 20 days of Medicare approved SNF care.

b. There are daily co-payments for the 21st through the 100th day of Medicare approved Medicare SNF. (See Table B for amounts.)

2. Medicaid will pay the Medicaid per diem rate less any Medicare payment but no more than the Medicare coinsurance amount.

B. Medicare Hospitalization Benefits

1. Hospitalization benefit period

a. Begins when the individual enters for the first time:

(1) A general hospital

(2) A nursing home where he is Medicare approved for SNF care

b. A new benefit period begins 60 continuous days after discharge from his last hospital or Medicare approved SNF.

c. An individual who goes from care in a nursing facility which is not Medicare approved SNF to a hospital may establish a new benefit period.

2. Diagnosis Related Groups (DRG) Reimbursement.

a. A set fee, based on the hospital's classification under Medicare and the patient's diagnosis, is incurred on the date of admission.

(1) The entire Medicare Part A deductible is due on the date of admission provided a new hospital benefit period has begun.

(2) When splitting the patient's PML between the hospital and the nursing facility, use only the Part A deductible for the portion assigned to the hospital instead of the actual hospital charges or per diem. Request the amount the a/r owes to the hospital. The PML is not changing in EIS, only to whom it is assigned.

REVISED 11/01/11 – CHANGE NOTICE 17-11

(XIV.B.2.a.(2))

b. If the patient is not admitted under DRG, he is responsible for actual daily hospital charges until the Medicare Part A deductible is met.

(1) Use the actual daily charges at the Medicaid per diem, until the Medicare Part A deductible is met when splitting the PML.

(2) If the amount of PML not already owed to the NF for the month is less than the Part A deductible, assign that amount as PML to the hospital.

3. From Medicare approved SNF to the hospital, the a/r may remain in the same benefit period with no responsibility for the Part A deductible, but with the possibility of co-insurance responsibility.

4. Be sure to involve the hospital business office and/or NF since their knowledge of Medicare coverage assists in determining the a/r’s responsibility to the hospital.