In Part 1 of our CMSCG “Ftag of the Week” for F582 Medicaid/Medicare Coverage/ Liability Notice, we reviewed the regulatory requirements that providers need to be aware of related to notification of residents about their Medicaid eligibility, items and services covered (or not) and refund requirements. In Part 2, we will review what you need to know related to Beneficiary Notices. The Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) are two areas where the guidance to surveyors was expanded and revised with the October 2022 updates.
Notice of Medicare Non-Coverage (NOMNC)
The facility is responsible for providing the NOMNC (Form CMS-10123) to a Medicare beneficiary at least two days before the end of the beneficiary’s Medicare-covered Part A stay will end, or when all Part B therapies are ending. Important information included in this form explains to the beneficiary his/her right to an expedited appeal by a QIO. Facility staff should explain this information to the beneficiary so it is clear.
There are several situations when a NOMNC is not provided. These include when:
- A beneficiary has exhausted his/her SNF benefits – 100 days – which means the Medicare Part A SNF benefit has been exhausted.
- A discharge from the SNF is initiated by the beneficiary.
- The hospice benefit has been elected by the beneficiary.
- The beneficiary chooses to revoke the Medicare hospice benefit and return to standard Medicare coverage.
Documentation related to these notices being issued is important for the facility to show that it has provided appropriate notice to a patient/resident regarding coverage. Timely notice allows for the beneficiary to appeal if he/she disagrees with the date noncoverage will begin. It’s also important to ensure the resident/ representative’s signature is obtained on these documents to show that the notice was issued and received.
Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN)
The facility is also responsible for informing a beneficiary about potential noncoverage for services, and the individual’s option to continue services if the beneficiary chooses to accept financial liability for the services. The SNF ABN is only issued when a beneficiary intends to continue services for which the SNF believes will likely not be covered by Medicare. Th purpose of this notice is to inform a beneficiary so he/she can choose to continue receiving skilled services that may not be covered by Medicare. That would mean assuming full financial responsibility for those services, so by providing the SNF ABN, the facility has informed the beneficiary of his/her potential financial liability related to care and services and the appeal rights the beneficiary has. As such, it is extremely important to ensure that this notice is provided when triggered.
The form requires the SNF to select a reason that it feels coverage will not be continued, and per the Interpretive Guidance (IG) in Appendix PP, the SNF ABN must be provided when one of several events occur. The IG references the Medicare Claims Processing Manual triggering events, which include initiation, reduction or termination.
SNF ABN Triggering Events
Initiation
The SNF must provide a SNF ABN to a beneficiary when it believes Medicare will not pay for extended care services or items that have been ordered by a physician. The notice must be provided before non-covered services/items are provided since the individual could become responsible for their payment.
Reduction
A SNF ABN must be provided to a beneficiary when the SNF is proposing to reduce the extended care services/items provided to a beneficiary because it anticipates that Medicare will not pay for a subset of items/services or will not pay for items/services at the frequency/level of care ordered by the physician. The notice must be provided in advance of any reduction to services or items being provided.
Termination
The third event which triggers a SNF ABN to be issued is when the SNF is proposing to stop providing all extended care items/services to a beneficiary because the SNF believes that Medicare will no longer continue to pay for the items/services that have been ordered by a physician and the beneficiary would like to continue receiving care. The notice needs to be issued before the SNF terminates extended care items/services.
Demand Bills
The SNF is responsible for filing a demand bill when it is requested by the beneficiary. Medicare-covered Part A services may not be charged to the beneficiary during the demand bill process.
During Survey
During survey, the surveyor will complete the SNF Beneficiary Notification Review for residents who have received Medicare Part A services to ensure the residents were provided with appropriate, timely information about their potential financial liability for services and their appeal rights for Medicare service coverage denial. The NOMNC and SNF ABN are reviewed during this survey task – so make sure your residents are receiving these notices as required.
Common issues identified during this review on survey include:
- Facility is unable to provide evidence that a SNF ABN was issued at least two days prior to a resident’s last covered day for Medicare Part A stay and the resident remained in the facility.
- Facility did not provide NOMNCs to residents whose Part A services were discontinued and the residents remained in the facility after services ended.
Don’t forget – only three residents are reviewed during this survey task. If the surveyor finds issues with all three residents reviewed, you could be looking at a widespread deficiency.
