Q&A: Takeaways from the 1135 waiver

Q: What changes brought about by the 1135 waiver will most affect case managers, and what should they know about these modifications?

A: The 1135 waiver covers a lot of ground. It is imperative that case managers are up to speed with the many changes that have been implemented.

The waiver does each of the following:

• Three-day qualifying inpatient stay for SNF coverage is eliminated.  Typically, Medicare requires that a beneficiary complete three inpatient days in a hospital before qualifying for skilled nursing facility (SNF) coverage. This is no longer necessary. Patients can now access SNF services if they were hospital inpatients, received observation or emergency department services, or were referred for services by a physician, or from home—provided they meet medical necessity criteria for SNF services.
• Coverage is extended beyond the Part A 100-day limit. Patients who have exhausted their 100 days of SNF coverage will continue to be covered beyond the 100-day mark. To receive this exemption, organizations should use the same DR condition code on the claim that they use to indicate a patient without a three-day qualifying stay.
• Stay limits waived for CAHs. Previously, critical access hospitals (CAH) could not exceed 25 patients, and patients could not exceed 96 hours in a stay. These limits have been waived. This change may give large acute care hospitals the ability to transfer patients who aren’t critically ill to these facilities for care, says Ronald Hirsch, MD, FACP, CHCQM, CHRI, vice president of R1 Physician Advisory Solutions in Chicago.

For additional information on changes made by the 1135 waiver, please see April’s issue of Case Management Monthly.