Giving up skilled nursing beds (SNF) is all about Medicare, what it pays for, what it doesn’t pay for, what it costs to comply with federal CMS regulations to qualify as a facility that can provide Medicare covered treatment.
General rules:
· Medicare pays for care in a SNF only if it is for short-term rehab following a 3-night qualifying stay in an acute care hospital. If a patient does not qualify, Medicare pays for short-term rehab services only on an outpatient basis (physical therapy, occupational therapy, speech therapy), which you may get at home, or in an assisted living facility, or even in a SNF. Medicare is just not picking up an AL or SNF daily room and board rate for care in a facility. (Certain ACO's and certain Medicare Advantage Plans can waive the 3-day requirement.)
· If you qualify, what does Medicare pay for SNF care in 2024? If you have Original Medicare, you pay these amounts for each benefit period:
o • Days 1–20: $0
o • Days 21–100: $204 each day
o • After day 100: You pay all costs
· Medicare has never paid for long-term or custodial care in a SNF nor for Assisted Living.
Collington in Maryland gave up its SNF licenses in 2023 and applied for additional AL licenses for several reasons.
· The first is declining SNF occupancy particularly for short-term rehab. Changes in medical practices and policies mean that fewer patients qualify under Medicare for inpatient short-term rehab in a SNF. They go home and get Medicare-covered short-term rehab on an outpatient basis (physical therapy, occupational therapy, speech therapy). Not only are their own residents not qualifying for Medicare-covered SNF care, CCRCs with SNFs that take external patients are getting fewer and fewer of these patients. Empty beds are a financial drain.
· The high cost of complying with federal Medicare regulations covering SNFs. The reporting requirements alone are burdensome. State regs for assisted living are generally less burdensome.
· Changes in medical practices and changes in state regulations have made it possible to care for patients with more complex needs in assisted living who formerly would have had to be cared for in skilled nursing.
What does their CCRC giving up their SNF mean for residents? If you don’t have the Medicare-required 3-night acute care hospital stay to qualify for Medicare reimbursement in a SNF, then you most likely get short-term rehab or respite care in your CCRC’s Assisted Living. If you reach a point where you need the round the clock care formerly provided in the SNF, you will receive that care in AL. We were told that Collington would maintain SNF level staffing in its AL, specifically that there would be an RN 24/7, which Maryland does not require for Assisted Living facilities.
What if you do have the 3-night qualifying stay and doctor’s orders for short-term rehab? The answer largely depends on the type contact you have. Collington has both type A (lifecare) contracts and type C (fee for service).
If you have a type C contract, you pay the appropriate daily rate for the level of care. When the CCRC has a SNF, Medicare reimburses for the daily rate. When it doesn’t and you get your short-term rehab in AL, you pay the CCRC daily rate. If you qualify for Medicare, it would be to your financial advantage to go an off-campus SNF where Medicare will pay.
If you have a type A lifecare contract, your monthly rate doesn’t change as you move through levels of care. Your contract likely provides for a temporary stay in a higher level of care for short-term rehab or respite with a return to your IL unit. So you can happily return to campus at no cost (perhaps a charge for additional meals). However, it would be to the CCRC's financial advantage to have you at an off-campus SNF where Medicare would reimburse.
At Collington, most residents have signed privacy waivers to allow the community to be informed when they are hospitalized or discharged or in rehab off campus or temporarily in our Health Cener etc. A social worker emails transition notices a couple of times a week. So we get to see some residents going to off-campus SNFs (Collington has informal relationships with two nearby ones) and other residents coming straight back to the Health Center for rehab or respite. Of course, we don’t know why any given resident is going anywhere. I speculate that it is those with type C contracts who go off-campus and those with type A who come home. It may also depend on how intense their therapy needs are. I have heard that at least one of the off-campus SNFs provides more intensive, twice a day, 7 days a week therapy. But certainly a great many are being discharged from a hospital stay and coming straight back to a temporary stay in AL for rehab or respite and those who comment on their stay in a post on the resident listserve are generally very positive.
Theoretically, Collington is providing transportation for spouses and friends to visit residents in off-campus SNF rehab. It was much discussed on the resident listserve a year ago but I have not seen any commentary lately. Given our staff shortages, my guess is that spouses and friends are coping on their own and have given up expecting Collington to provide transportation. I see posts from residents who no longer drive saying If you are going to Future Care to visit someone, I would love a ride so I can visit .___.
There are all sorts of combinations of possibilities and it is worth sitting down with your marketing person and going through a variety of what ifs to be sure that you understand your particular CCRCs contracts. I would not view discontinuing the SNF as a deal breaker. But you do want a clear understanding of what to expect in a variety of circumstances
Lorrie Rogers
Collington