Medicare Eligibility

[nratchet]

If a patient was admitted to the hospital, had the required 3 day stay, went to a Skilled SNF for 26 days, went home for 20 days and then was admitted to a different Skilled SNF, is he qualified for Medicare coverage?

For some reason my fellow coordinators keep remembering a 7 day rule, i.e. the patient can be discharged home from the hospital but still be eligible for Medicare coverage in a Skilled SNF if they are admitted within 7 days.

There is also the 30 day rule, but our admissions coordinator seems to believe that a stay in another Skilled SNF extends the 30 days.

Help!

[Talino]

If a patient was admitted to the hospital, had the required 3 day stay, went to a Skilled SNF for 26 days, went home for 20 days and then was admitted to a different Skilled SNF, is he qualified for Medicare coverage?

For some reason my fellow coordinators keep remembering a 7 day rule, i.e. the patient can be discharged home from the hospital but still be eligible for Medicare coverage in a Skilled SNF if they are admitted within 7 days.

There is also the 30 day rule, but our admissions coordinator seems to believe that a stay in another Skilled SNF extends the 30 days.

Help!

After an SNF discharge, the resident may be readmitted to the same SNF or another within 30 days and be entitled to Med A coverage (as long as benefit days are still available) provided the current skilled need is related to the condition for which resident was treated for during the original hospital stay (prior to 1st SNF adm).

There is no such thing as a 7-day rule. After a hospital stay, a resident can be discharged home, and be admitted to the SNF within 30 days and receive Med A coverage, as long as the skilled care requirement is related to the condition treated during the hospital stay.

http://www.cms.hhs.gov/manuals/Downloads/bp102c08.pdf from p9

[Rexie68]

I agree with Talino....as long as it's within 30 days of discharge and the admission is related to the original hospital stay, Medicare A coverage applies. It still amazes me that the "experts" often don't have a clue what the rules are. The RAI manual is pretty clear on this one. :bowingpur

[limarie]

It is 30 days and just make sure that the reason for skilling the patient is related to that 3 day qualifying stay.

[edhcinc]

Hi--the previous responses are all correct, but we should also remember another helpful caveat:

This is from the manual noted above:

A3-3132, SNF-214

Care in a SNF is covered if all of the following four factors are met:

1. * The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel (see 30.2 - 30.4); are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services;

Here is a scenario..

• A person is in the hospital for hip fracture repair. He comes to your SNF for rehab.
  
• Three days before rehab is completed, he develops a UTI which is treated with po antibiotics. He goes home with a prescription for 7 more days of treatment, and continued rehab at home. He does NOT fill the prescription, because he "feels fine".
  
• Two weeks later, he goes to the ER because he has blood in urine and a temp of 102.
  
• His attending MD (who is also the facilitly medical director) decides that he needs a 7 day course of IV antibiotics, and admits him back to the SNF. (He is not reliable enough to administer his own IVAB at home.)
  
• Assuming he still has MC Part A SNF benefit days available, his stay is coverable under Med A because he is re-admitted within 30 days of the SNF stay for a condition which arose during the SNF stay following a qualifying hospital stay.