Ask Diane: What should we do when a resident has Managed Medicaid and Part C?
Q: A resident in our facility is covered by a Managed Medicaid plan and also has Medicare Part C. She did not have a qualifying hospital stay and is now ordered to receive physical therapy five days a week. Is this a skilled service? Should we do a 5-day PPS assessment and bill for payment on a RUG? Also, does this break her 60 day period of wellness and should we start counting the 60 days over again when she is discontinued from therapy?
Diane: Physical therapy is considered a skilled service under Medicare Part A when it meets the criteria included in Chapter 8 of the Medicare Benefit Policy Manual. One of these requirements is that the therapy must be provided five or more days a week. However, these requirements only apply to services covered by Medicare Part A and this particular resident has Medicare Part C, or Medicare Advantage. Every Part C plan may have a unique set of rules and requirements, so check with this resident’s plan to determine if the physical therapy is considered a skilled service.
You would not have to do a 5-day PPS assessment or bill for payment on a RUG unless these are required by the Part C plan. So be sure to check your contract with the Medicare C provider.
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Diane Brown
Diane Brown is a long-term care regulatory specialist and lead educator for HCPro's MDS 3.0 Boot Camp and Medicare Boot Camp-Long-Term Care Version. She is also a long-term care consultant with over 25 years of operational experience in healthcare. For Diane's complete bio, visit the About page.
Diane has written 240 posts.
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Comments
would she still not have to have a qualifying stay to initiate a covered Medicare claim?
M/C part C plans are required by law to provide the same services as traditional M/C part A- however, these plans routinely fail to follow this federal rule/law. If the Resident is ordered and receiving “skilled services” and these services rise to meet administrative criteria then you should follow the PPS schedule of assessments. Some plans waive the 3-day hospital stay rule for accessing the “part A benefit”. I would advise you to do the 5-day (combine it with a significant change if warranted), start the PPS schedule of assessments and then check with the Plan. Resident’s managed M/A will pay the co-pay’s if this plan has any.
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