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Inpatient hospital entitlement changes

When a patient enrolls in or disenrolls from a Medicare Advantage plan during his/her inpatient stay, the following factors will determine whether to bill the Medicare Advantage plan and/or original Medicare.

  1. The hospital provider receives prospective payment system (PPS) payments, or is exempt from PPS payments, or is a non-PPS provider; and
  2. The date of enrollment/disenrollment with the Medicare Advantage plan

Inpatient PPS provider billing guidelines

The patient’s entitlement status at admission determines liability for inpatient acute care hospitals, inpatient rehabilitation facilities (IRFs), or long-term care hospitals (LTCHs) that receive PPS payments.

If the patient was not enrolled in the Medicare Advantage plan at the time of admission and enrolls before discharge:

  • Bill the entire inpatient stay to Medicare for payment
  • Medicare Advantage plan organization is not responsible for payment

If the patient is enrolled in a Medicare Advantage plan at the time of admission and disenrolls before discharge:

  • Bill the entire inpatient stay to Medicare Advantage plan for payment, and,
  • Submit a no-pay claim to Medicare to report the patient’s inpatient utilization days 

Exempt PPS inpatient provider billing guidelines

Providers that are inpatient children hospitals, cancer hospitals, and psychiatric hospitals/units exempt from PPS must split bill the appropriate coverage portion of the patient’s inpatient stay with Medicare and Medicare Advantage plan. 

Example:

The patient is admitted on September 28 and discharged October 13 and enrolls in a Medicare Advantage plan effective October 1. Split bill as follows:

  • Bill Medicare for dates of service September 28 through September 30; and,
  • Bill Medicare Advantage plan for dates of service October 1 through October 13, and include necessary supporting documents; and
  • Submit a no-pay claim to Medicare for dates of service October 1 through October 13 to report the patient’s inpatient utilization days

Non-PPS inpatient provider billing guidelines

Inpatient hospitals that do not receive PPS payments must also split bill and may only bill the Medicare Advantage plan for dates of service that fall within the coverage period enrollment and disenrollment dates.

 

Reference

  • CMS IOM, publication 100-04, Chapter 1, section 90