THE INEQUITY OF MEDICARE COPAYMENT is a structural deficiency in the SNF revenue-cycle unrelated to the Patient Driven Payment Model, which establishes patient-specific per diem rates across a Medicare Part A Benefit Period (up to 100 days). Medicare pays providers 100% of the PDPM rate for days 1 – 20, then applies a $200/day coinsurance reduction to the remaining (up to) 80 days. Beneficiaries without a supplemental Medigap policy must pay coinsurance out-of- pocket, which providers are required to pursue.
“Dual-eligible” beneficiaries are enrolled in both Medicare and Medicaid. Medicare Part A is the “primary” payer for qualifying SNF short-term care; Medicaid, as “secondary” insurer, is charged the $200/day coinsurance (Medicaid assumes primary-payer status after the Medicare benefit is exhausted). Federal Medicare policy is consistent across the nation; Medicaid is administered at the state level, with payment rules so variable they perversely distort the Medicare benefit Medicaid is designed to support.
