Ask the Experts

Ask the expert: HMO coverage

Q: I am new to my current facility, but to my understanding the main biller wants us to submit all MDS assessments to CMS, even for HMOs, due to the facility not getting paid some time ago when the resident actually switched from a HMO to Medicare while they were in their 100 days.

I told her I would look in to this because my understanding is this:

  1. If the resident has a HMO, you only submit the admission assessment to CMS and 5-day, 14-day assessment would get coded out as a 1 in section A0410.
  2. If the resident changes plans during this cycle (from HMO to Medicare) a new 5-day assessment has to be done as they are now Medicare and not an HMO.

Please clarify.

A: Only if the resident is in a Medicare Part A stay would you submit the Medicare assessments (5-day, 14-day, etc). This topic has been discussed by CMS several times in order to stop facilities from sending in assessments that are in violation with current regulations (i.e., HIPAA).

For HMO and managed Medicare residents, a facility can complete the assessment, but may not transmit to the ASAP database. You are correct, the OBRA assessments are completed as usual.

Most software packages will calculate a RUG score for non-Medicare Part A residents and place the score in the Insurance section of the MDS.

Facilities have the option to transmit to the appropriate insurance company if the company is set up to do so. In the event that the resident transitions from a manage care plan to traditional Medicare Part A, there are transition rules in Chapter 5 of the MDS User’s Manual and Chapter 6 of the IOM 100-04 Medicare Claims Processing Manual.