case study question? Skilled Med A services

  1. If you have a resident that is on Medicare with a RUGS SE2 has a stage 3 ulcer, O2 and a few other things that qualify him for that Rug group and 35 days after admission he is put on Hospice with a prognosis of 6 months does he still qualify for Med A services?? When would skilled services end??
    Do I need to so an OMRA?? And if initial services do end, would he qualify for skilled medicare and when?? Thanks ahead for everyone who helped!
  2. Visit jpav33 profile page

    About jpav33

    Joined: Jan '08; Posts: 20

    3 Comments

  3. by   Talino
    Med A SNF benefits end on day 1 of hospice enrollment. Altho' a resident may receive SNF and hospice benefits simulatenously if the conditions are unrelated.

    Since the previous RUG score is already a non-Rehab (SE2), an OMRA is not required. If it were a Rehab RUG, an OMRA would only be required if therapy was dc'd and resident continues to receive skilled services 8-10 days before the 1st day of hospice.

    Whenever the hospice benefit is revoked during a certain period, resident may access Med A benefits again.

    Medicare Benefit Policy Manual (Hospice)
    http://www.cms.hhs.gov/manuals/Downloads/bp102c09.pdf

    Medicare Benefit Policy Manual (Part A)
    http://www.cms.hhs.gov/manuals/Downloads/bp102c08.pdf
  4. by   poohmdsnurse
    First off I have a few questions for you- when was he cut from Medicare A?
    Two, he would not qualify for Medicare A when he goes Hospice- you can't be medicare A and Hospice at the same time. No OMRA needed, that is only when you cut someone from therapy and still keep them skilled.
    Third, anyone who you would want to pick back up Medicare A would have to have been cut within the last 30 days.
    I guess your only thing I would think about is doing a new quarterly (since we are in a new quarter now)on him if he is medicaid to increase your RUGS score, barring that he will still be here at the end of the quarter(June 30,2008).
  5. by   RN 4 Life
    I agree with Talino and poohmdsnurse....in addition you can also be an advocate for the patient and their family by helping them make the best decision.
    Determine if the patient will be eligible to use both Medicare Part A and Hospice benefits. The patient may be eligible to continue to use their Medicare Part A benefit and Hospice if the primary dx and reasons for treatment are different and unrelated.
    For example, the patient is skilled for Medicare Part A for the daily care of a Stage 4 wound which requires aseptic technique and prescription medication...and will be admitted to Hospice with a primary diagnosis of end stage renal disease.Use the resources Talino provided to review these concepts in more detail.

    If the family is not eligible to use both, help the family make an informed decision regarding whether to proceed to hospice. Make sure they are aware that Hospice only covers treatment and services related to the primary diagnosis, pain and some other Hospice related care and services. Probably more importantly from a financial perspective [which can be a determining factor for most families] Hospice does not cover room and board and any medications that are not related to the primary diagnosis that the family may want the patient to have. This can cost the family a significant amount of money if they do not have a secondary payor to absorb the cost.

    I hope this helps.

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