Ask the Experts

Ask the expert: Medicare Advantage plan

Q: If a beneficiary changes from one Medicare Advantage plan to another, do they automatically get 100 new days of Skilled Nursing? MAO’s do not report days paid to the Common Working file and unless the SNF informs the new plan of days paid under another plan or that the beneficiary has had previous stays  we may not know if they have used days. How should this be handled?

A: Each Medicare beneficiary is entitled to 100 days per spell of illness, regardless if it is under Part A fee for service or Part C (MA) or any combination of the 2 types of Medicare coverage.  It is the responsibility of the facility to remit a bill to Medicare to deduct days from the CWF, which maintains this data.  I¹m providing the Manual excerpt that mandates this practice.

IOM 100-04 MCPM, Ch 6, §90.2 – Medicare Billing Requirements for Beneficiaries Enrolled in MA Plans (Rev. 1394, Issued: 12-14-07, Effective: 10-01-06, Implementation: 03-17-08)

If a beneficiary chooses an MA plan as his or her form of Medicare, he/she cannot look to traditional “fee for service” Medicare to pay the claim if the MA plan denies coverage.  SNF providers shall apply the following policies to MA beneficiaries who are admitted to a SNF:

  • If the SNF is non-participating with the plan, the beneficiary must be notified of his or her status because he/she MAY be private pay in this circumstance, depending upon the type of MA plan in which he/she is enrolled.
  •  If the SNF is participating with the plan, pre-approve the SNF stay with the plan;
  •  If the plan denies coverage, appeal to the plan, not to the ³fee for service² FI;
  • Count the number of days paid by the plan as Part A days used (this IS the beneficiary¹s 100 days of Medicare SNF benefits);
  • Submit a claim to the “fee for service” intermediary to subtract benefit days from the CWF records.

(Note: The plans do not send claims to CWF for SNF stays). Failure to send a claim to the FI will inaccurately show days available.