Center for Medicare Advocacy Toolkit: How to Obtain an Additional 100 Days of Medicare Coverage in a Skilled Nursing Facility During the COVID Public Health Emergency

As the Public Health Emergency (PHE) continues and the number of Medicare beneficiaries impacted by the PHE grows, the Center for Medicare Advocacy (the Center) has received an increasing number of requests for guidance on expanded Medicare coverage in skilled nursing facilities (SNFs).

The following are a compilation of self-help materials that include articles written by the Center (citing CMS guidance), detailed CMS instructions to obtain the waiver, and an interpretation of the additional 100 day waiver as adjudicated by a Medicare Administrative Law Judge (ALJ):

• Our July 2020 CMA Alert discussing the Centers for Medicare and Medicaid Services (CMS) detailed guidance about how to obtain up to an additional 100 days of SNF coverage. https://medicareadvocacy.org/cms-clarifies-covid-waivers/
• A June 2020 CMA Alert discussing a case study of the 100 day waiver and a full explanation of when the additional coverage would apply, and when it would not. Here is a link to the article:  https://medicareadvocacy.org/covid-19s-impact-on-beneficiary-rights-a-case-study-examining-medicare-coverage-exceeding-100-days-in-a-skilled-nursing-facility/

Traditional Medicare Cases: CMS has issued a Medicare Learning Network (MLN) article that explains exactly how to bill for the 100 days, including necessary coding and language required to be included in the remarks section (COVID100). Without working through the specific billing requirements, CMS states that the claim will not be processed.  https://www.cms.gov/files/document/se20011.pdf

Medicare Advantage Plan Cases: A Medicare ALJ decision shared with the Center by a beneficiary details the steps used by the ALJ to award an additional 100 days of coverage, overruling organization determinations and the independent review entity’s denial of the additional days. The redacted decision is at: https://medicareadvocacy.org/wp-content/uploads/2020/09/COVID-19-100-extra-days-in-SNF-OMHA-decision.pdf.

A note of caution about Medicare’s 1135 blanket waivers, providing flexibility under section 1812(f) of the Social Security Act: A PHE waiver that extends SNF benefits by up to 100 days does not appear to afford beneficiaries the same rights as the first 100 days of statutory coverage. In a letter written in response to a congressional inquiry about the issue, CMS noted that the benefit extension under the PHE is at the discretion of the facility. CMS stated, “Our goal with these waivers is to provide flexibility for the wide variety of challenges that SNFs face during the pandemic. In such circumstances, blanket waivers allow facilities to apply provisions without the need to request them from CMS, thereby allowing SNFs to address very local and very specific challenges. If the SNF would like to cite and document…The SNF may choose to exercise that provision of the 1135 blanket SNF waiver…” The redacted CMS letter is at: https://medicareadvocacy.org/wp-content/uploads/2020/09/CMS-redacted-letter-re_-congressional-inquiry-PHE-100-day-waiver.pdf