Medicare Recipient

QMB eligible

Up to 20 Days with a Medicare skilled NF need:

• SPL - None required
• PAS - No service eligibility determination required
• Liability-None
• Plan of care- None (no state payment)
• Consider OSIPM eligibility under Acute Care Settings rule (ACS case descriptor)
• Transition - Identify individuals with potential to transition to HCBS, monitor progress throughout SNF service for transition readiness

Day 21- up to 100 with a Medicare skilled NF need:

• SPL - None required
• PAS - Verify Medicare A coverage for SNF service; if Medicare is reimbursing for SNF services, Medicaid co-pay can be authorized
• Liability-None
• Plan of Care- None (state pays co-pays only)
• Consider OSIPM eligibility under Acute Care Settings rule (ACS case descriptor)
• Transition - Identify individuals with potential to transition to HCBS, monitor progress throughout SNF service for transition readiness and assist with transition planning

SMB/SMF eligible

Up to 20 Days with a Medicare skilled NF need:

• SPL - None required
• PAS - No service eligibility determination.
• Liability-None
• Plan of Care-None (no state payment)
• Transition - Identify individuals who have potential to transition to HCBS, monitor progress throughout SNF service for transition readiness and assist with transition planning.

• Medicare will not pay for unskilled care.  If individual does not meet the Medicare skilled criteria, OSIPM eligibility is required
• Keep SMB/SMF if no need for medical transportation or ongoing long-term care. If need medical transportation or LTC, determine eligibility for OSIPM:
  • Anticipate a 30 day stay
  • Under 300%
  • Under OSIPM resource limit
  • Timely continuing benefits decision notice (SDS 540) is then necessary when reducing back to SMB/SMF

Day 21- up to 100 with a Medicare skilled NF need:

• PAS - Must have OSIPM eligibility as there is no co-pay coverage for SMB or SMF clients. If OSIPM-eligible, verify Medicare A coverage for SNF service; if Medicare is reimbursing for SNF services, Medicaid co-pay can be authorized.
• Transition - If the individual with SMB/SMF will soon be OSIPM-eligible, monitor for completion of Medicare A SNF service to determine the individual’s need for ongoing long-term service, identify potential for HCBS and assist with transition planning.

• Note: If the individual has resources below $2000 and no asset transfers, they will most likely be eligible for OSIPM (461-135-0745).

OSIPM eligible

Up to 20 Days with a Medicare skilled NF need:

• SPL - None required
• PAS - no service eligibility determination
• Liability- None
• Plan of Care- None (no state payment)
• ACS is not necessary for individuals with income under the OSIPM adjusted income standard.
• Transition - Identify individuals  with potential to transition to HCBS, monitor progress throughout SNF service for transition readiness and assist with transition planning.

Day 21- up to 100 with a Medicare skilled NF need:

• SPL - None required
• PAS - Verify that the individual is receiving Medicare A coverage for Skilled NF services. If Medicare is reimbursing for SNF services, Medicaid Co-pay can be authorized.
• Liability- None
• Plan of Care- None (co-pays only)
• ACS is not necessary for individuals with income under the OSIPM adjusted income standard.
• Transition - Identify individuals who have potential to transition to HCBS, monitor progress throughout SNF service for transition readiness and assist with transition planning.

No Medicare skilled NF need, or skilled stay has ended (long-term care):

• SPL - required to be eligible for NF benefit
• PAS - (1) Determine that individual’s service needs meet SPL; and (2) Determine if the individual can be served in HCBS or if NF is required to meet service needs.
• Liability- Calculate per  OAR 461-160-0620
• Plan of Care- Yes
• Transition - Identify individuals who can transition to HCBS and assist with transition planning.

No Medicaid

OSIPM/QMB eligibility needs to be determined.  For OSIPM, use the 300% income standard. Once determined, see above.

Individual with no Medicare

MAGI or OSIPM eligible

Managed care – up to 20 days:

• Plan decides benefit and NF payment, no SPL
• Plan will pay for a maximum of 20 days
• SPL needed at day 21
• PAS - Plan pays benefit; no service eligibility determination
• Transition - Monitor the individual to assure discharge from the NF following the 20-day benefit. For individuals with anticipated long-term service needs, initiate or refer for Medicaid application.

Fee-for-service days – up to 20 days:

• If the individual has a 3-day qualifying hospital stay and a skilled service need (using Medicare criteria): 
• SPL - None required
• PAS - Service eligibility for OHP 20-Day Post Hospital Benefit: (1) Three-day qualifying hospital stay; and (2) A “Medicare A Skilled”-type service need.
• Liability- None
• Plan of Care- None
• Transition - Monitor to assure discharge from the NF following the 20-day benefit. For individuals with anticipated long-term service needs, initiate or refer for Medicaid application.
• If there is no qualifying hospital stay or no skilled need:
• SPL - required
• Need OSIPM or MAGI eligibility
• PAS - (1) Determine that individual’s service needs meet SPL; and (2) Determine if the individual can be served in HCBS or if NF is required to meet service needs.
• Plan of Care- Yes
• Liability- Calculate per OAR 461-160-0620
• Transition – Identify individuals who can transition to HCBS and assist with transition planning.

Days 21 + (long-term care):

• SPL - required
• Need OSIPM or MAGI eligibility
• PAS – (1) Determine that the individual’s service needs meet SPL; and (2) Determine if the individual can be served in HCBS or if NF is required.
• Plan of Care- Yes
• Liability- Calculate per OAR 461-160-0620
• Transition – Identify individuals who can transition to HCBS and assist with transition planning.

No Medicaid

MAGI or OSIPM eligibility needs to be determined. For OSIPM, use 300% standard (may need PMDDT decision). Once determined, see fee-for-service above.