Ask the Experts, News, Skilled Nursing Facility

Ask the expert: Medicare Advantage

Q:  We have a resident being admitted with a new G-tube, NPO status and receiving all nutrition via tube feeding.  The resident is Medicare Advantage (Humana).  Under the Medicare Benefit policy manual this would be considered a direct skilled nursing service, so we could potentially skill this resident for 100 days since it is the beneficiary’s need for skilled care.  It has been my understanding that Medicare Advantage plans follow the same guidelines as Medicare Part A, as per the Medicare Benefit Policy Manual. However, when our Business Office contacted Humana regarding this particular resident, they said they would not be able to cover for 100 days on the need for skilled services for the tube feeding.  Is this correct?

A:  I’m enclosing the Medicare Basic Rule for covered services.

100-16 MMCM, CH4 Benefits and Beneficiary Protections, §10.2 Basic Rule An MA organization (MAO) offering an MA plan must provide enrollees in that plan with all Part A and Part B, Original Medicare services, if the enrollee is entitled to benefits under both parts, and Part B services if the enrollee is a grandfathered ³Part B only² enrollee. The MAO fulfills its obligation of providing Original Medicare benefits by furnishing the benefits directly, through arrangements, or by paying on behalf of enrollees for the benefits.

It is also true that a beneficiary with G-Tube that receives at least 26% of the calories and 501ml of fluid through that tube is considered skilled under Medicare Part A.

This being said, it is not an automatic 100 days because of the variables related to medical necessity.  It is up to 100 days if the beneficiary continues to meet the coverage guidelines. The patient could potentially be weaned off the tube, the patient may be discharged back to the community before the 100 days is concluded, or the patient may not need the tube. Also in order to determine what the next step to take would be, you need the timeframe that would be covered (at least initially) by the Medicare Advantage insurer.

It’s important to know exactly how this was presented to the insurer in order to fully answer your question. Did you receive an initial authorization? Can you receive additional authorizations depending on the condition of the patient? Or did they outright deny the skilled care?

There is an appeals process that can be initiated, but the denial of the authorization must be in writing along with the rationale and the appeals proces.