Guest blogger Brandon Fields is an elder law attorney in Boulder, Colorado. He works with seniors, their families and the disabled. Caregiver children form a large portion of his clientele. He has written a thorough post for us to understand the intricacies of this complex topic.
If you are a Medicare beneficiary with Part A hospitalization coverage and you are hospitalized for three days or more, you may be entitled to skilled care for rehabilitation in a skilled nursing facility. However, you should know the rules to obtain your full benefits.
Qualifying for Rehabilitation with Medicare
In order to qualify, you must be admitted to a hospital on an inpatient basis for three days. The day of admission counts as one of the three days, but the day of discharge does not count. So, for example, if you are admitted on a Monday and discharged on Thursday morning, you have met the three days. However, if you are discharged on Wednesday night before midnight, it is considered only a two-day stay, and you will not be eligible for the Medicare skilled care rehabilitation benefit.
If you are in the hospital for observation, since observation is considered “outpatient status”, each day or days of observation will not count toward meeting the three-day requirement. As recently as March 30, 2012, the American Medical Association has written to Medicare asking to change the rules to include observation in the three days, but no change has been made to date. Time spent in the emergency room prior to admission, also will not count toward the three days.
Receiving Rehabilitation in a Skilled Nursing Facility with Medicare
If you have met the three days, your doctor must then order skilled care to be provided in a skilled nursing facility (SNF) on an inpatient basis. Examples of skilled care are treatments provided by, or supervised by:
- Registered nurses
- Licensed practical nurses
- Physical therapists
- Occupational therapists
- Speech language pathologists
Your skilled care in the SNF must be provided on a “daily basis” as defined under the Medicare rules. Skilled care services in the SNF is considered to be provided on a daily basis if it is offered at least 5 days per week.
The Relationship of Hospitalization and Rehabilitation with Medicare
You must then enter a Medicare certified SNF within thirty days of the hospitalization for the same condition for which you were treated in the hospital. So, for example, if you are sent directly home from the hospital after a fall, but ten days later require admission to a SNF for rehabilitation for medical issues from that fall, your stay in the SNF will qualify, since you are still within thirty days of the hospital discharge. Also, if you leave the SNF after some rehabilitation, but have to go back within the same thirty-day period after the hospitalization, you will not need to have had another 3 day hospitalization to qualify for the skilled care benefit.
The SNF will assess your needs and make a care plan for your treatment. You and your family, or your health care agent under power of attorney, have the right to have a conference with facility staff in helping to plan your care plan.
Medicare Rehabilitation Co-Pay
If you qualify for the Medicare benefit for skilled care, Medicare will pay for up to one hundred days of such care. The first twenty days Medicare will pay the full cost of such care and for the next 80 days the patient will have to pay a co-pay. The 2012 co-pay is $144.50 per day. Most private Medicare supplemental insurance policies (sometimes called Medigap policies) will pay the co-pay during the additional 80 days. While you are receiving skilled care in the SNF, Medicare will also cover the cost of a semi-private room, meals, medications and dietary counseling.
After 100 days, Medicare will no longer pay for the skilled nursing facility. The patient will either leave the skilled nursing facility, will have to pay privately from their own savings, or rely on another source of payment, such as long term care insurance, a veteran’s benefit through the Veterans Administration, or Medicaid. If the patient has another three day stay in the hospital, even in the same calendar year, another one hundred day period will start for skilled care. If you must leave the SNF for a hospitalization, even if you are again eligible for skilled care, there is no requirement that the SNF hold a bed for you, and you may have to go to another Medicare certified SNF that has a bed available.
Skilled Nursing Facilities Advanced Beneficiary Notice of Non-Coverage
During the one hundred day period, you may find that the skilled nursing facility determines you no longer need skilled care that is covered by Medicare. In order to do this the facility must issue to you or your agent under health care power of attorney a “Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage” terminating the Medicare coverage. In effect, the facility is making a determination that you will no longer benefit from the skilled care.
Two common issues sometimes result in an inappropriate early termination of the skilled care benefit:
First, the nursing home may terminate the benefit solely because the patient is not making measurable improvement toward a rehabilitation goal. However, the Medicare regulations also require coverage where the patient continues to need the skilled care to maintain their current status or not to deteriorate from their current health status.
Second, the facility may terminate if assistance is only being provided by a non-skilled staff member. However, Medicare would still be required if the care needs to be “supervised” by a skilled care provider such as a nurse. For example, supervision by a nurse or other skilled provider where multiple treatments are being provided with a potential for adverse interactions among them in the absence of skilled supervision.
Medicare Quality Improvement Organization
If you disagree with the notice of non-coverage, you are eligible for a fast appeal to a Quality Improvement Organization (QIO) designated by Medicare to review such decisions. The contact information for the specific QIO must be included on the notice of non-coverage. If you choose to appeal, this will also cause the relevant records to be submitted to the QIO and may result in additional coverage. You can also ask providers, such as physicians or nurses to provide information you can submit to the QIO with your appeal. There is no cost to the patient for the review. The patient will not be required to privately pay the skilled nursing facility for the days at issue until after a determination has been made by Medicare on the review. If the QIO determination is not favorable, you can further appeal for a hearing before an administrative law judge.
About the Author:
As an elder law attorney Brandon helps clients find solutions to a wide array of issues, including long term care planning, estate planning, Medicare, guardianship and conservatorship and special needs trusts for the disabled. Brandon is also the co-chair of the elder law section of the Colorado Bar Association and frequently speaks in the community on elder law topics.