Medicare Compliance & Reimbursement

How to reduce paperwork and liability - and maximize benefits for residents.

Are skilled nursing facilities doing all they can to promote great family relations while securing for each qualified resident an extra $600 in federal funding?
 
When Medicare launched its new "transitional assistance" drug cards for Medicare beneficiaries in nursing homes in May, only 14 percent of those eligible for the benefit signed up. Confusion seems to abound among both consumers and providers, according to the Centers for Medicare & Medicaid Services.
 
Wake-up call: Providers may also be in the dark about the program, attorneys close to the issue say.

 "They must either think they know what they are doing or they don't even have a clue," surmises one, commenting on the lack of inquiries he's received from providers.
 
Crash course: Transitional assistance, which is part of the Medicare Discount Drug Program that CMS rolled out May 3, refers to the $600 annual funding that certain low-income Medicare beneficiaries can receive to help cover their out-of-pocket drug costs.
 
Though transitional assistance can apply to Medicare beneficiaries enrolled in Part A or Part B, only the nursing facility resident who is low-income and paying privately for drugs (that is, someone who is "spending down" to Medicaid) would be eligible for the benefit. The transitional assistance benefit is not open to residents in a Medicare Part A stay since their drug costs are covered under the postacute Part A benefit.
 
Eligibility for the special assistance is based on income, not assets, notes Paul Baldwin, chief executive officer of the Long-Term Care Pharmacy Alliance, which offers the LTC Card and which represents four major national long-term care pharmacies. In most states, nursing homes need to confirm that the person is a Medicare beneficiary with an annual income of no more than $12,569 for a single person or $16,862 for someone who is married (income ceilings are significantly higher in Hawaii and Alaska).
 
Keys to understanding: CMS, through its QIES Technical Support Office (http://asp.qtso.com/stso/start.asp) has issued an "Alert" listing four essential related documents for distribution to nursing home administrators.
 
Don't forget: Providers must also double-check to ensure the resident applying for transitional assistance does not receive outpatient drug coverage from other sources, such as Medicaid or federal employees health benefits.
 
Fraud watch: Don't bill prescription medicines to Medicaid until a resident's $600 benefit is exhausted, cautions the Alabama Nursing Home Association.
 
Though nursing homes have no obligation to help identify beneficiaries who might qualify, or to help them apply, doing so can be a great boost to community and family relations.
 
For information, contact your pharmacy provider or one of the three groups offering the transitional assistance cards for nursing home residents: