Medicare provides coverage for up to 100 days a year for skilled nursing facility care. During the first 20 days, the full cost of care is covered. Beginning with the 21st day, the individual has a copayment obligation. Oftentimes the Medicare coverage is triggered when the person is going directly from a hospital to a nursing facility.
Financial eligibility shall continue to be determined based on the provisions of 8172 during the Medicare coverage period allowing for the full cost of the nursing facility care even though a portion or all of that cost is being covered by Medicare. Thus, for example, if the individual's patient liability is less than the state approved rate per 8172 (2), he or she is eligible regardless of whether Medicare benefits are being provided and the nursing facility is subject to the applicable state rate in regards to what, if anything, can be billed to Medicaid and/or the client during this time.
For clients whose liability is less than the state approved rate per 8172 (2), if the Medicare payment made exceeds the applicable state rate for the facility in a month, no further payment is due the home from either the client or the agency. However, there may be instances in which the Medicare payment may fall short of the state rate. Where this occurs, the client and/or agency will likely be responsible for payment depending on whether the individual is QMB eligible or not. This is because the amount of the client's co-insurance is an allowable expense for liability and payment purposes.
In these instances if the individual is QMB eligible, the Medicare payment to the facility and any additional Medicaid payment, where the Medicare payment does not exceed the state rate, is considered payment in full and the individual has no further payment responsibility. This is because the QMB program is responsible for payment of all Medicare co-insurance charges, including the nursing facility related charges. For all other individuals, the facility will get paid only at the state rate either through the client's liability or a combination of the liability and any agency payment.
As the amount of Medicare payment can never be adequately projected for a month, the Medicare period should be treated as though an Medicaid payment will be made. A patient liability should be calculated and transmitted via the LOTC screen for both QMB and non-QMB clients and a notice to the nursing facility. Since the first 20 days of the Medicare period may also not be accurately assessed, particularly if some of these days had been previously used, the patient liability and payment effective dates should correspond to the date the client enters the facility rather than delaying to the 21st day. For all intents and purposes, the case should appear as if there were no Medicare days involved. It would then be the responsibility of the nursing facility to correctly bill for these days.
For QMB clients, both the individual and nursing facility must be notified that there is no obligation during the Medicare coverage period. For non-QMB clients in notifying the individual of his or her liability during the Medicare period, it should be noted that only a portion of the liability may be due to the home or possibly none of the amount dependent upon how much Medicare pays for the client's care that month. If the Medicare payment is greater than what Medicaid would pay, the client would owe nothing further to the home. If it is less, the client would be responsible for the difference up to the liability amount. This same notation should appear on the notice to the nursing facility so that they are aware of the limitation.
It should be noted that where the client does not end up paying any liability because of QMB coverage or the amount of Medicare payment, the possibility of excess resources may occur. Both the client and/or family should be made aware of this possibility so that ineligibility does not result.
See Policy Memo 2007-09-01, Long Term Care Partnership Information. Insurance coverage is available to help pay the cost of long term care. Generally, most of these policies allow for payments to be made either to the client or the nursing facility. These are treated as a third party liability and need to be noted in the MMIS. As such, the client should be instructed to have the benefits assigned directly to the facility.
Financial eligibility shall continue to be determined based on the provisions of 8172 allowing for the full cost of the nursing facility care even though a portion or all of that cost is being covered by the insurance. This is similar to how Medicare days are treated per 8181 above. Thus, for persons where liability is less than the state approved rate per 8172 (2), he or she is eligible regardless of whether Long Term Care Insurance benefits are being provided and the nursing facility is subject to the applicable state rate in regards to what, if anything, can be billed to Medicaid and/or the client during this time. If insurance benefits exceed the applicable state rate for the facility, no further payment is due from either the client or the agency. If the benefits fall below the state rate, the client and/or agency will then be responsible for the remaining payment up to the state rate based on the amount of client liability.
Regardless of the situation, a patient liability should always be calculated and transmitted via KEES screen as well as notification provided to the nursing facility for persons meeting the provisions of 8172 (2). The liability and payment effective dates should also correspond to the date the client enters the facility.
Notification to the client should follow the guidelines set in 8181.
As noted in 2666, medical assistance is available to a child or young adult under the age of 21 residing in a Medicaid approved institution for long term care. Eligibility shall be determined based on the provisions contained in this section (8100) including the establishment of appropriate eligibility periods outlined in 8130, the absence of a resource test as indicated in 8142(2), the separate treatment of income in accordance with 8143 (3), the long term care income standards of 8160, and the determination of financial eligibility per 8170. See also 2666 and 8112.4 concerning children in an institute for mental disease.
For individuals age 18 and over, the temporary stay policies of 8113 are also applicable if the individual qualifies under another medical program.
See Policy Memo 2016-08-01, re: Long Term Care Changes.
This form is used by the facility to communicate specific information to the eligibility worker regarding status which may impact payment to the facility. In most instances, the facility is required to maintain a copy of all MS-2126 forms sent and received. The facility is required to send a new MS-2126, Notification of Facility Admission/Discharge form in the following situations:
The nursing facility is responsible for submitting the completed MS-2126 to the KanCare Clearinghouse within 5 days of the events/request described above. Failure to timely submit the form may cause a delay or denial of payment to the facility. See also Section 7030 of the Nursing/Intermediate Care Facility Provider Manual.
KDADS or its designee and eligibility staff shall take appropriate steps to ensure that if an NF loses Medicaid certification help is given in the transition to the Medicaid customers who will need to find new residence. Specific instructions for eligibility staff will be given by KDHE-DHCF Policy if this need should arise. Eligibility staff are responsible for notifying the resident and the resident's family or guardian of any continuing financial responsibility.
Generally, private rooms are not covered except when medically necessary or when utilized at the discretion of the facility. However, if a private room is not medically necessary or is not occupied at the discretion of the facility, a family member, guardian, conservator other third-party may reimburse the difference between the usual and customary charge the Medicaid payment rate.
Because the NF program provides for room and board and all services and supplies required by residents in an NF, the NF may not charge program customers for providing routine services and supplies. The cost of providing such items is included in the home's per diem rate and is not to be billed or reimbursed.
In addition, a nursing facility may not charge an eligible recipient any amount in addition to the patient liability in order to expedite entry into the nursing facility or as a condition of entry or continued stay in the nursing facility. A nursing facility may charge for services required by the customer which are not considered by the agency to be part of the per diem rate, such as newspapers, smoking materials, etc. In addition, non-covered medical services (see 8172.1 (2)(b)) are also the responsibility of the client.