An official State of Texas website.
Revision 09-4; Effective December 1, 2009
Under certain limited conditions, Medicare will pay some nursing facility (NF) costs for Medicare beneficiaries who require skilled nursing or rehabilitation services. To be covered, the person must receive the services from a Medicare-certified skilled nursing facility (SNF) after a qualifying hospital stay. A qualifying hospital stay is the amount of time spent in a hospital just before entering a nursing facility. This is at least three days. Care must begin within 30 days after leaving the hospital. The person’s doctor must order daily skilled nursing or rehabilitation services that the person can get only in an SNF. "Daily" means seven days a week for skilled nursing services and five days a week or more for skilled rehabilitation services.
| Number of Days | Person's Responsibility | Medicare's Responsibility |
|---|---|---|
| 1-20 | Nothing | Everything |
| 21-100 | 20% — the SNF care co-payment per day paid after 20 days of Care (21-100). See Appendix XXXI, Budget Reference Chart. | The rest |
| Over 100 | Everything | Nothing |
O-5210 Medicaid Coverage Code Issues
Revision 12-2; Effective June 1, 2012
- T coverage code is not a Medicaid coverage code. T indicates Community Attendant Services (CAS) coverage providing Medicaid payment for attendant care only. This coverage code does not provide for NF vendor payment, doctor visits, hospital stays, medically necessary items or prescription drug coverage.
- R coverage code is a Medicaid coverage code. R indicates regular Medicaid coverage providing Medicaid payment for NF vendor payment, doctor visits, hospital stays, medically necessary items or prescription coverage. Medicaid is the payer of last resort and a medical necessity is required for vendor payment in an NF. Vendor payment is also subject to co-payments. R coverage provides for payment of prescription drug coverage except when the person is dually eligible for both Medicare and Medicaid.
- Q coverage code is a Qualified Medicare Beneficiary coverage code. Q indicates that Medicaid pays the Medicare premiums, deductibles and co-insurance, including Medicare-covered hospital and NF stays.
Examples
Example 1: When a person with only coverage code Q (only active EDG is MC – QMB – also known as a Pure Q) enters an SNF from a hospital, Medicare will cover 100% of the SNF vendor costs for days 1-20. Medicare will cover 80 percent of the SNF vendor costs for days 21-100. As a Pure Q person, Medicaid's Q covers 100 percent of the remaining 20% of the SNF vendor costs for days 21-100. The person will not be responsible for the remaining 20% of the SNF vendor costs – the Medicare co-pay per day for days 21-100. As a Pure Q person, the person is not responsible for the amount of co-payment an MEPD-eligible individual must pay for nursing care.
Note: If the person does not remain a Pure Q person and becomes certified for MEPD, use Example 2.
Example 2: When a person living in the community enters an SNF from a hospital and is dually eligible for both Medicare and Medicaid (MQMB with both R and Q coverage), Medicare will cover 100% of the SNF vendor costs for days 1-20. Even though the person is MEPD eligible, test the person for institutional coverage that is subject to transfer of assets and excess home equity policy. The 30-day stay requirement is not necessary. If the person is eligible for MEPD and co-payment:
- retroactive adjustments to ensure the correct benefits will be necessary;
- the person will not be responsible for the remaining 20% of the SNF vendor costs – the Medicare co-pay per day for days 21-100; and
- the person will have a calculated MEPD co-payment beginning day 21.
Notify the person of the responsibility for the MEPD co-payment.
Example 3: When a CAS person (T coverage code only) who has Medicare enters an SNF from a hospital, Medicare will cover 100% of the SNF vendor payment for days 1-20. Medicare will cover 80% for days 21-100. The person’s MEPD eligibility in an NF (R coverage) needs to be determined. Test the person for institutional coverage that is subject to transfer of assets and excess home equity policy. The 30-day stay requirement is necessary. If the person is eligible for MEPD with co-payment:
- retroactive adjustments to ensure the correct benefits will be necessary;
- the person will not be responsible for the remaining 20% of the SNF vendor costs – the Medicare co-pay per day for days 21-100; and
- the person will have a calculated MEPD co-payment beginning day 21.
Notify the person of the responsibility for the MEPD co-payment.
Example 4: When a CAS recipient with Qualified Medicare Beneficiary (QMB) only (T and Q coverage codes) enters an SNF from a hospital, Medicare will cover 100% of the SNF vendor payment for days 1-20. Medicare will cover 80% for days 21-100. The person's MEPD eligibility in an NF (R coverage) needs to be determined. Test the person for institutional coverage that is subject to transfer of assets and excess home equity policy. The 30-day stay requirement is necessary. If the person is MEPD eligible for vendor payment:
- retroactive adjustments to ensure the correct benefits will be necessary;
- the person will not be responsible for the remaining 20% of the SNF vendor costs – the Medicare co-pay per day for days 21-100; and
- the person will have a calculated MEPD co-payment beginning day 21.
Notify the person of the responsibility for the MEPD co-payment.
If the person is not MEPD eligible for vendor payment but is eligible for Pure Q, notify the person and use Example 1.