🏥 SNF and Nursing Facility Coverage Summary

Medicare vs. Medicaid: Different Purposes

Medicare Part A (SNF) pays for short-term skilled nursing or rehab after a qualifying 3-day hospital stay.
Medicaid (NF/LTC) pays for long-term custodial care once the patient no longer needs daily skilled therapy and meets income/resource limits.
The same facility can operate under both programs; what changes is who’s paying and what type of care is being covered.

Covers up to 100 days per benefit period if medical and hospital-stay criteria are met.
Pays the facility a bundled per-diem rate that includes room, board, nursing, and most supplies/equipment.
While Part A is active, Part B DME can’t be billed separately — all services and equipment are part of the SNF bundle.
After day 100 (or when skilled need ends), Medicare Part A coverage stops; Part B can resume for eligible outpatient or home-based services.

Covers long-term custodial care (help with ADLs, maintenance therapy, routine nursing).
Pays the facility a vendor per-diem rate plus collects the resident’s applied income (their share of cost).
That daily rate already includes routine medical equipment and supplies, so DME can’t be billed to TMHP separately.
Custom or personal-use items not included in the vendor rate can sometimes be funded through an Incurred Medical Expense (IME) deduction.

When neither Medicare A nor Medicaid is paying, the stay is private pay.
The patient is treated as being “at home” for Medicare B/DME purposes.
DME suppliers may bill Medicare B normally (POS 12 = home) and Medicaid secondarily, since no per-diem is in effect.

Applied Income = the portion of a Medicaid resident’s monthly income paid to the facility toward their care.
IME (Incurred Medical Expense) = Medicaid’s mechanism for allowing part of that applied income to be used for medical costs not covered by Medicare, Medicaid, or the facility’s per-diem (e.g., custom equipment, dentures, hearing aids).
HHSC approves IMEs so residents can pay suppliers directly without violating Medicaid cost-sharing rules.

Stay Type	Primary Payer	DME Billing Allowed?	Notes
Medicare A SNF	Medicare A (per-diem)	❌ No	DME included in SNF bundle
Medicaid NF (applied income)	Medicaid vendor rate	❌ No (except via IME)	Routine DME bundled
Private Pay	Resident/family	✅ Yes	Bill Medicare B as “home”
Medicare A exhausted / no skilled need	None or Medicaid	✅ Yes (if not per-diem)	Bill Part B if patient “home”

Medicare A = short-term rehab, everything bundled.
Medicaid NF = long-term care, routine items bundled.
Private pay = bill normally.
When in doubt, check who’s paying the room & board — that tells you whether your DME can be billed.