CMS Updates Guidance on Nursing Home Waiver Provisions

The Centers for Medicare and Medicaid Services (CMS) has updated the Medicare Learning Network (MLN) Matters article on Medicare fee-for-service (FFS) billing to provide further clarification on the appropriate use of the skilled nursing facility (SNF) benefit period waiver flexibilities. The article reiterates that unlike the waiver of the 3-day inpatient qualifying hospital stay (QHS), which does not require separate determination that the individual’s circumstances are impacted by the COVID-19 Public Health Emergency (PHE) to be applicable, the benefit period flexibility is applied in a more restrictive way. To qualify for the benefit period waiver (which in certain cases allows an individual to qualify for skilled nursing even if they have not yet completed the customarily required break in service), it must be demonstrated that a beneficiary’s continued receipt of skilled care in the SNF is in some way related to the PHE. In making such determinations, a SNF resident’s ongoing skilled care is considered to be emergency-related unless it is altogether unaffected by the PHE itself (that is, the beneficiary is receiving the very same course of treatment as if the emergency had never occurred).

CMS urges providers to make sure that they use the criteria provided in the article in determining when to document on a Medicare claim that the patient meets the requirement for the waiver and asks providers to work with the Medicare Administrative Contractor (MAC) to provide any documentation needed to establish that the benefit waiver applies. The guidance appears on page 11 of the updated article, which was originally published in March and is available here.

Contact: Darius Kirstein, dkirstein@leadingageny.org