Skilled Nursing Facilities (SNFs) must issue a notice to Original Medicare (fee for service - FFS) beneficiaries in order to transfer potential financial liability before the SNF provides an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or custodial care.
Skilled Nursing Facilities
SNFs must not add any customizations to the notice beyond what is permitted by the accompanying SNF ABN form instructions and the guidelines published in this section. SNFs should follow the same standards when completing the SNF ABN as the ABN, Form CMS-R131 in §50.6 of this chapter, as applicable. See also "Advanced Beneficiary Notice (ABN)"
A SNF ABN is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay. If Medicare is expected to deny payment (entirely or in part) on the basis of one of the exclusions listed in §70 of this chapter for extended care items or services that the SNF furnishes to a beneficiary, a SNF ABN must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary. The initiation, reduction and termination of such extended care items or services, that Medicare may not pay, are considered triggering events. The following describe the three triggering events
for a SNF ABN:
|Initiation||In the situation in which a SNF believes Medicare will not pay for extended care items or services that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it furnishes those non-covered extended care items or services to the beneficiary.|
|Reduction||In the situation in which a SNF proposes to reduce a beneficiary’s extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequency of care that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it reduces items or services to the beneficiary.|
|Termination||In the situation in which a SNF proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNF ABN to the beneficiary before it terminates such extended care items or services.|
SNFs need not issue a SNF ABN to transfer financial liability to the beneficiary:
• If the extended care item or service is not a Medicare benefit (e.g., personal comfort items excluded under §1862(a)(6)).
• If a beneficiary is being furnished post-hospital extended care services while a resident in a SNF and payment is expected to be denied for an otherwise Medicare covered benefit because it does not meet a technical benefit requirement (e.g., SNF stay not preceded by the required prior three-day hospital stay or the beneficiary is exhausting his/her 100 benefit days).
• If Medicare is expected to deny payment for Part B covered medical and other health services which the SNF furnishes, either directly or under arrangements with others, to an inpatient of the SNF, where payment for these services cannot be made under Part A (e.g., the beneficiary has exhausted his/her allowed days of inpatient SNF coverage under Part A in his/her current spell of illness or was determined to be receiving a non-covered level of care).
• If the SNF will not furnish the extended care items or services. A SNF must not give a beneficiary a SNF ABN and then refuse to furnish extended care items or services even though the beneficiary elects to receive these items or services by selecting Option 1, as this is equivalent to the prohibited practice of the SNF pre-selecting Option 2 (not to receive items or services) on a SNF ABN. This rule also applies when the beneficiary agrees with the triggering event (i.e., terminating therapy) and the beneficiary will not be receiving the extended care items or services.
NOTE: This rule is not applicable in the situation where the beneficiary elects to receive extended care items or services but refuses to sign the SNF ABN attesting to being personally and fully responsible for payment, in which case, the SNF may then consider not furnishing the specified items or services.
For Medicare Advantage (Part C) enrollees nor for non-Medicare patients because it is to be used solely for individuals enrolled in the Medicare FFS program (Parts A and B).
• When extended care items or services are reduced or terminated in accordance with a physician’s order, where a physician does not order the items or services at issue, or where the physician agrees in writing with the SNF’s, the UR entity’s, the QIO’s, or the Medicare contractor’s assessment that the extended care items or services are not necessary.
• For swing-bed determinations. The Preadmission/Admission HINN (HINN 1) should be given.
When completing and delivering the SNF ABN, SNFs must meet the written notice standards in §50.6 and 50.7 of this chapter, unless otherwise specified. Failure to provide a proper SNF ABN in situations where a physician has ordered the extended care item or service may result in the SNF being held financially liable under the LOL provisions, where such provisions apply. SNFs may also be sanctioned for violating the conditions of participation (42 CFR 483.10) regarding resident (beneficiary) rights.
NOTE: The SNF ABN is not a replacement for, but is in addition to, the required UR entity notices. The SNF ABN protects the SNF from liability in the event the beneficiary, for some reason, does not receive the UR entity notice.
Questions regarding the SNF ABN or ABN can be submitted at: https://appeals.lmi.org/
For Part A items and services: SNFs use the SNF ABN as the liability notice.
For Part B items and services: SNFs use the Advance Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131.