Qualifying for Medicare A - Talino, can you help?

[Mama Jules]

I have many years of experience but right now cannot put my hand on the Medicare reg about qualifying stays. Here's my predicament:

01/09/2015: Resident admitted under Part A services after a qualifying event.

01/22/2015: Discharged from Part A after refusing therapy services and no longer any nursing skilled services provided. Met the criteria for intermediate level of care under Medicaid guidelines.

05/20/2015: Admitted to the hospital for surgery r/t non-healing wound (appeared after 30 window to re-skill had closed).

05/21/2015: Re-admitted to unit after a one night stay in a regular (non-observation) bed.

06/05/2015: Admitted to hospital for worsening of wound.

06/08/2015: Re-admitted to unit.

***What are the guidelines concerning when the 60 day spell of wellness (less than skilled) occurs? Will the break in stay on 05/20 preclude her from Medicare A benefits OR since she had 60 days of wellness prior to that stay, can we pick her up under her A benefits again?

[Talino]

The 60-Day wellness period began 1/23/15 when resident stopped receiving a skilled service. Granting the resident never received skilled care thereafter or was not hospitalized on or prior to 3/23/15, he/she would have satisfied the requirement.

A 3-day hospitalization which occurs any time after 3/23/15, entitles resident to a new spell of illness (a new benefit period of 100 days) granting the skilled care requirement is met.

The 5/21 – 5/22 hospitalization has no effect to that wellness period.

Therefore, with the new 3-day hospitalization of 6/5 – 6/8, the resident may now avail of the full 100-day benefit period.

[Mama Jules]

Thank you. I thought I was right....but you know every now and then a newbie comes along with a new perspective and makes me second guess myself.

Do you have link to the page in the manual I could refer to? I know I've seen it in there, but I have scoured both chapter 6 and 8 of the (Medicare) manual and dang if I can find it.

[Talino]

http://www.medicare.gov/publications/pubs/pdf/10153.pdf

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