Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
This week’s trend for questions on HarmonyHelp include the 3-night qualifying stay for Medicare Part A Benefits in a (SNF) Skilled Nursing Facility.
“We had a resident admitted from a VA Hospital that we accepted for skilled services and rehabilitation services (Part A). We came to find that the VA Hospital in question is not Medicare-certified and told us that "one government entity cannot bill another government entity such as Medicare.” We were told that the resident will not have a qualifying stay unless the VA facility was Medicare certified and can bill Medicare for services. Is this accurate?”
A three-day hospital inpatient stay is needed to qualify for the SNF Medicare Part A Coverage under the Medicare benefit.
However, a stay in a Department of Veterans Affairs (VA) hospital that is not Medicare Certified may qualify an individual for Medicare Part A SNF Coverage if the VA hospital meets Medicare's definition of an emergency hospital.
To meet the emergency hospital definition, the hospital must follow:
- certain hours of service,
- nurse staffing, and
- state or local licensing requirements.
Chapter 8 of the Medicare Benefit Policy Manual specifies in §20.1 that the hospital in which a qualifying 3-day stay takes place
“need not actually participate in Medicare, as long as it meets at least the definition of an emergency hospital”
contained in §20.2 of the Chapter 5 Medicare General Information, Eligibility, and Entitlement Manual.
Chapter 5 defines an emergency hospital as:
“A nonparticipating hospital which meets the requirements of the law’s definition of a “hospital” relating to full-time nursing services and licensure under State or applicable local law.”
The “hospital” definition in §20 of that chapter, in turn, sets forth those two requirements as follows:
- Provides 24-Hour Nursing Service rendered or supervised by a registered professional nurse, and has a licensed practical nurse or registered professional nurse on duty at all times;
- Is licensed or is approved by the State or local licensing agency as meeting the standards established for such licensing.
The emergency hospital definition in §20.2 further clarifies that
“A Federal hospital [such as a VA hospital] need not be licensed under State or local licensing laws to meet the definition of emergency hospital.”
Per CMS, the above option in the hospital definition enables an emergency hospital simply to be “approved” as meeting the standards for State or local licensure (rather than being required to obtain such licensure) recognizes that Federal facilities do not always obtain a license from the applicable State or local authority.
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