The regulations surrounding issuance of beneficiary notices has resulted in some significant confusion in the SNF industry, not only with SNF staff, but with surveyors as well. Compounding the confusion is not only knowing which of the different types of forms to issue, but who and when to issue them, to be in compliance with current Federal regulations.
New CMS Updates
Discussions related to beneficiary notices has recently resurged for 2 different reasons. First, the new survey process, implemented in November 2017, now mandates the review of a nursing facilities compliance with beneficiary notices, and secondly, CMS released an updated Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) that SNF providers must implement on or before May 7th, 2018. The new SNFABN must replace any other notifications (old SNFABN or denial letters) a facility may currently be using.
The purpose of the various beneficiary notices is based on different regulations and serve 2 different purposes:
- Informs the beneficiary of any potential liability for items or services that will not be covered by Medicare
- Informs the beneficiary when the provider (or health plan) determine that the beneficiary no longer meets skilled coverage criteria.
CMS has developed and mandates the use of several different notices to meet both of the above regulatory requirements. Each of the notices are required to be issued at specific times and under specific circumstances. Some notices only apply to traditional Medicare Part A beneficiaries while the other notices apply to both traditional Medicare Part A beneficiaries and Medicare Advantage enrollees.
When to Issue the SNFABN
The SNFABN is to be issued, to traditional Medicare Part A beneficiaries, when the SNF believes that Medicare will not pay or will no longer continue to pay for a SNF stay when it is determined that a beneficiary does not require daily skilled nursing or rehabilitation services. In other words, the Medicare beneficiary does not meet the “skilled level of care” criteria. This level of care determination is primarily made prior to admission to the SNF as well as throughout a beneficiaries Part A SNF stay. The issuance of the SNFABN would correlate with the “level of care” determination at these 2 different times.
The SNFABN is not required to be issued when the reason for non-coverage is related to the beneficiary not meeting the ‘technical’ criteria for SNF coverage (e.g., no 3-day hospital stay, no benefits available, not admitted within 30 days of hospital discharge). In addition, the SNFABN is NOT to be issued to Medicare Advantage enrollees.
SNFABN Upon Admission: The SNFABN would be issued either prior to or upon admission to the SNF when a resident meets all technical criteria (e.g. 3-day hospital stay, SNF benefit days available, admitted within 30 days, etc.) to access their SNF Medicare Part A benefits but does not present with a need for daily skilled rehabilitation or nursing services.
SNFABN Upon Termination of Part A: This is the most common scenario in which a SNFABN would be issued. A SNFABN must be issued when the SNF determines that the resident’s Medicare Part A stay will be terminating AND the resident will continue to reside in the SNF. The purpose of issuing the SNFABN at this time is to notify the beneficiary of their potential financial liability (either privately, Medicaid or other insurance) for any items or care received once the Medicare stay ends.
The SNFABN is not required to be issued if the resident is going to be discharged, from the facility, immediately upon termination of their Medicare Part A stay since there would be no further financial liability.
The second regulatory requirement is to notify Medicare beneficiaries when the provider or the beneficiary’s health plan makes a determination that the beneficiary no longer meets skilled coverage criteria and plans to terminate Medicare coverage. The notice given to comply with this regulation is referred to as the Notice of Medicare Non-coverage (NOMNC). The NOMNC is required to be issued to BOTH traditional Medicare Part A beneficiaries as well as Medicare Advantage plan enrollees.
The NOMNC is required to be issued a minimum of 2 days prior to the last day of skilled coverage. Similar to the SNFABN, the NOMNC is NOT required to be issued if the reason for ending skilled coverage is due to an exhaustion of available benefits.
Keeping in mind that we must satisfy 2 different requirements, some residents would require the issuance of both of the notices discussed.
Example: Resident under a Medicare Part A stay and utilizes 45 days of their SNF benefit. Medicare Part A coverage ends due to no longer requiring a skilled level of care and the beneficiary will remain in the SNF under Medicaid.
In this scenario BOTH notices would be provided. The NOMNC would be issued 2 days prior to their last covered Medicare Part A day AND the SNFABN would be issued, on or before their last covered day, to notify the resident of their financial liability for any continued stay in the SNF effective the day after their Medicare coverage ends.
As previously mentioned, compliance with the beneficiary notices for Part A residents is a mandated task under the new survey process. To assist both surveyors and SNF providers in understanding these requirements, CMS has developed a SNF Beneficiary Protection Notification Review Pathway. This Pathway also includes additional scenarios to demonstrate the notice requirements.
According to the Pathway surveyors will be required to review 3 randomly selected residents from a list of Medicare Part A discharges within the past 6 months. The surveyor will then give the provider a Beneficiary Notice Checklist to complete for each of the 3 selected residents.
To minimize the possibility of a F582 citation, now is the time to assess your understanding and compliance with these requirements and ensure your organization meets the May 7th, 2018 deadline to implement the new SNFABN.