Medicare Part A

Introduction

Hospital insurance.

Coverage:

• hospitalization
  • beneficiary pays deductable of $1260
    • beneficiary pays $315/day for days 61-90 of each benefit period
• skilled nursing home
  • covers (in full) 1st 20 days of nursing home care after hospitalization
  • covers $144/day (2016) for days 21-100 of nursing home admission provided patient requires nursing care
  • patient is responsible for $185.50 per day for days 21-100 in 2021
    • Medicaid will cover copayment for days 21-100 if eligible
  • Medicare part A does not pay for skilled nursing facility without a qualifying hospitalization (see Eligibility below)
• covers skilled home health care for up to 60 days
  • nursing assessment & teaching (patient or caregiver education)
  • physical therapy
  • speech & language therapy services
  • medical monitoring (eg, vital signs, weight), wound care, medication management
  • Medicare does not cover home occupational therapy, social work, or personal care home health aide services in isolation
    • if there is a qualifying skilled need (physical therapy, speech therapy ...), occupational therapy & a home health aide to assist with bathing is covered
  • does not cover home health for
    • phlebotomy for laboratory testing
      • phlebotomy as part of a car plan to actively manage a recently unstable medical condition is allowed
    • monitoring glycemic control
    • home health aide
    • physician home visit (covered by Medicare part B)
• hospice

Eligibility:

• must meet eligibility criteria
• 3 day stay in acute hospital for stay in SNF
  • SNF stay must be needed for
    • a condition treated during the qualifying hospital stay, or
    • a condition that arose in the SNF for which the patient was previously treated in a hospital
  • daily skilled care on an in-patient basis required & certified as such by an attending physician
• home health services
  • must be considered home bound (3 day stay in acute hospital not required)
  • face to face or telehealth visit by physician within 90 days
  • need for skilled-nursing care, physical therapy or speech therapy
  • home health agencies paid propectively for up to 60-day periods
  • home health services for dementia if patient is unstable
  • home health agencies at financial risk, thus permitted to manage case using protocols/care processes that are expected to obtain the specified outcome
• top 26 RUGs categories automatically eligible up to assessment reference date for 1st MDS assessment;
  • afterwards, clear documentation of:
    • continuing need for skilled care
    • medical justification that the services are reasonable & necessary
• for lowest 18 RUGs categories, eligibility can be determined on an individual basis, using established (albiet revised) administrative criteria

Deductable for part A is $1288 per benefit period (2016), i.e. 1st 60 days after an admission

Acceptance & administrative functions:

• before accepting patients, ensure they meet part A administrative eligibility criteria
• initial assessment by nurses & therapists
• define needs & begin treatments
• 1st MDS done on days 5-8
  • assessment reference date = last date of observation period
  • can be transmitted up to day 31 to HCFA
• software gives RUGs category based on MDS
  • largely based upon # of minutes of rehabilitation services during 7 day look-back period
  • these are determined by the appropriateness for each discipline based on patient's levels & goals
  • supported by patient's documentation
• TCU unit manager, in conjunction with therapists, determine appropriate level & timing of therapies
• 2nd MDS done on day 14
• continual evaluation of patient's level, progress, & goals
  • adjustment of regimen

Physicians must pay attention to:

• part A certification requirements
• MDS definitions
• Federal & state requirements
• medical necessity
• coding requirements
• billing requirements & documentation guidelines

What can physicians do?

• ensure that only accurate diagnoses & ICD9 codes are listed
• supply appropriate diagnoses & documentation to support part A coverage
• case management
• supply clinical input to ensure optimum MDS information
• order only medically necessary services & document medical necessity for such services
• act as patient advocates to ensure that all medically necessary services are provided
• stick to the PPS formulary
• thoroughly review all meds for appropriateness
• make sure all documentation is consistent with nursing & other documentation on the chart
• provide more frequent visits as required to prevent deterioration & potential ER visits
• physician visits & order changes are important documentation to support medical observation & evaluation under the clinically complex category

More general terms

• Medicare

Additional terms

• Medicare hospice benefits