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The July 30, 1999 SNF PPS final rule (64 FR 41666) describes an administrative presumption that when a beneficiary is correctly assigned to one of the upper 26 RUG-III groups under the initial 5-day, Medicare-required assessment, the SNF level of care requirement is met for the period from SNF admission up to and including the assessment reference date for that assessment. Although this presumption does not apply in connection with any of the subsequent assessments, the coverage that arises from the presumption remains in effect for as long thereafter as it continues to be supported by the actual facts of the beneficiary's condition and care needs. The following scenarios further clarify that a beneficiary's classification to one of the upper 26 RUG-III groups triggers the coverage presumption under the initial 5-day, Medicare-required assessment only when that assessment occurs directly following the beneficiary's hospital discharge. 1. Routine SNF Admission Directly
from Qualifying Hospital Stay 1. Routine SNF Admission Directly from Qualifying Hospital Stay It the beneficiary is admitted to the SNF immediately following a three-day qualifying hospital stay, there is a presumption that he or she meets the Medicare level of care criteria. The presumption lasts through the assessment reference date of the 5-day assessment. which must occur no later than the 8th day of the stay. 2. Admission to SNF does not immediately follow discharge from the qualifying hospital stay, but occurs within 30 days (as required under the "30 day transfer" rule) If the beneficiary is discharged from the hospital to a setting other than the SNF, the presumption of coverage does not apply, even if the beneficiary's SNF admission occurs within 30-days of discharge from the qualifying hospital stay. Accordingly, coverage would be determined based on a review of the medical evidence in file. 3. SNF Resident Is Re-hospitalized and then Returns Directly to the SNF If a beneficiary who has been in a covered Part A stay requires readmission to a hospital, and subsequently returns directly to the SNF for continuing care, there is a presumption that he or she meets the level of care criteria upon readmission to the SNF. A new Medicare 5-day assessment is required and the presumption of coverage lasts through the assessment reference date of the assessment, which must occur no later than the eighth day of the stay. 4. Routine SNF Admission Directly from Qualifying Hospital Stay, but Initial Portion of SNF Stay Covered by Another Insurer (Medicare as Secondary Payer) When a beneficiary goes directly from a qualifying hospital stay to the SNF, but the initial portion of the SNF stay is covered by another insurer that is primary to Medicare, Medicare coverage would not start until coverage by the insurer ends. The Medicare required schedule of assessments would not begin until the first day of Medicare coverage. If Medicare begins within the first 8 days of the stay, the presumption lasts through the assessment reference date of the 5-day assessment or, if earlier, the 8th day of the stay. Thus, if the other insurer's coverage lasts through the 8th day of the stay, there is no presumption. 5. Beneficiary Receives a Notice of Non-Coverage upon Admission and Requests a Demand Bill In this situation, a Medicare 5-day assessment was not performed because the SNF's clinical staff determined upon admission that the beneficiary did not meet the level of care criteria for coverage. For purposes of State compliance, the SNF did perform a 14-day assessment, on which the beneficiary classified into one of the upper 26 RlJG-III groups. For a beneficiary who correctly classifies into one of the upper 26 groups in this situation, there is a presumption that he or she meets the level of care criteria. In this case, the presumption would apply because the beneficiary qualified for one of the upper 26 RUG-III groups based on the 14-day assessment, which retroactively includes the initial period that would have been addressed by a 5-day assessment. However, since no 5-day assessment was actually performed, these days are paid at the default rate, and no grace days may be claimed in this case. Thus, the facility is eligible for only 5 days of payment based on the presumption. A demand bill reversal was done as follows: From day 1 (admission) up to and including day 5, payment is made at the default rate, since no Medicare assessment was performed. From day 6 forward, there is no Medicare payment or coverage. 6. Readmission to SNF within 30 Days after Discharge from Initial SNF Stay-No Intervening Hospitalization As noted in scenario 1, if a beneficiary is initially admitted to the SNF directly from the hospital for a covered Part A stay, the presumption for that stay is applicable. However, if that beneficiary is discharged (NOT to an acute care facility) and then subsequently readmitted, there is no presumption applicable to the second SNF admission. (If the beneficiary is transferred to a hospital, and returns directly to the SNF, see item 3 above) 7. Initial, Non-Medicare SNF Stay followed by Qualifying Hospitalization and Readmission to SNF for Medicare Stay Dually eligible (Medicare/Medicaid) beneficiaries whose initial stay in the SNF is either Medicaid-covered or private pay, are eligible for the Medicare presumption of coverage when readmitted to the SNF following a qualifying hospitalization. (Of course, in order to qualify for Medicare coverage upon readmission, the beneficiary must be placed in the portion of the institution that is actually certified by Medicare as a SNF.) 8. Transfer from One SNF to Another SNF There is no presumption of coverage in cases involving transfer of a beneficiary from one SNF to another. The presumption only applies to the SNF stay that immediately follows the qualifying hospital stay. Bear in mind that the presumption was deliberately designed so as to create a very high probability of identifying those situations that involve a need for skilled care. Accordingly, we do not anticipate that there will be a significant number of cases in which a beneficiary qualifies for the presumption and yet does not actually require any skilled care. However, as indicated in the final rule (64 FR 41668-69), if it becomes apparent in actual practice that this is not the case with regard to certain specific criteria under the RUG-III classification system (for example, the 14-day "look-back" provision), HCFA reserves the right to reassess the validity of the presumption's use of those criteria.
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