H-7400, Medicare and Medical Effective Date

Revision 09-4; Effective December 1, 2009

The medical effective date for a person in a Medicare skilled nursing facility (SNF) potentially can be as early as the first day of the month of entry to the nursing facility or the first day of a prior month. If eligible, this will ensure payment of any other medical expenses (including returns to the hospital during the initial 20 days of full Medicare coverage). At certification, the eligibility worker must verify and document in the case record that either the person:

• remains in the SNF section, or
• has been discharged to Medicaid.

Medicare approval of the applicant for the SNF meets the medical necessity (MN) requirement. If the medical effective date (MED) is prior to the applicant's move to Medicaid days in the facility, the MN requirement has been met.

Note: If the person remains in the SNF when the case is certified, it is recommended that a special review be scheduled to monitor for the completed MN determination when SNF does end.

Examples:

• Marsha Ford is admitted to an SNF as full Medicare on 11-15-XX. The 21st SNF day is 12-05-XX. Form H1200 is received 12-14-XX. Application is ready to certify 01-03-XX. The eligibility worker verifies that the person has unpaid/reimbursable hospital bills for 11-XX. Ms. Ford is still in the SNF days and has met all eligibility criteria as of 12:01 a.m. 11-01-XX. MED = 11-01-XX. Co-payment begins 12-05-XX.
• Fred McDaniel is admitted to an SNF as full Medicare on 03-24-XX. The 21st SNF day is 04-13-XX. Form H1200 is received 04-05-XX. He is discharged from the SNF to Medicaid on 05-20-XX. Application is ready to certify 06-15-XX. Mr. McDaniel meets all eligibility criteria as of 12:01 a.m. 03-01-XX. MED = 03-01-XX. Co-payment begins 04-13-XX. MN is not necessary, as MED is prior to discharge to Medicaid.