Rehab, and the hundred days that are not a hundred days

The three days that have to come first

Original Medicare pays for skilled nursing care after a hospital stay, and the word doing the work is after. The regulation requires at least three consecutive calendar days hospitalized as an inpatient for medically necessary care, not counting the date of discharge. A Monday admission and a Wednesday discharge is two qualifying days.

Time spent under observation is outpatient time and counts for nothing here, however many nights it lasted and however much it looked like a ward. This is a frequent way the benefit is lost, and it is lost before anybody has mentioned rehabilitation.

There is a clock on the other side too. The patient must need the care, be admitted, and receive it within 30 calendar days of leaving the hospital — with an exception where the care would not be medically appropriate that soon, in which case admission can wait until it would be appropriate to begin an active course of treatment.

If a parent is in a Medicare Advantage plan rather than original Medicare, the three-day requirement is treated differently: the regulation deems a beneficiary enrolled in such a plan at admission to have met it for the whole stay. Ask the plan, not the hospital, and ask early.

What a hundred days actually means

Up to 100 days are available in each benefit period. Medicare pays for all covered services for the first 20. From the 21st through the 100th day a daily coinsurance is the patient's responsibility, set annually, and it is not a token amount — it is the reason a family planning around a hundred paid days starts receiving bills in the fourth week.

The renewal rule is the one worth understanding, because it decides whether a second illness starts from zero. The full entitlement to hospital and skilled nursing days renews each time a new benefit period begins. The exception is the lifetime reserve: 60 non-renewable days on the hospital side that a patient may draw on beyond 90 days in a benefit period, and which can never be got back once used.

Sahvelo does not print the coinsurance figure, because it changes every year and a page carrying last year's number is worse than one carrying none. Ask the facility for the current daily amount in writing before the twentieth day, not after it.

“She has plateaued” is not a coverage rule

The belief that Medicare stops paying once a patient stops improving is repeated at care-planning meetings across the country and has been wrong in writing since 1983. The regulation says that restoration potential is not the deciding factor in determining whether skilled services are needed, and that even where full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.

What the rule does require is that the service be genuinely skilled: so inherently complex that it can safely and effectively be performed only by, or under the supervision of, professional or technical personnel. That is a real limit and it is where a maintenance case is actually decided.

There is a second door, and it is opened by the chart rather than by the argument. A service that is usually unskilled may be treated as skilled where special medical complications mean professional staff must perform or supervise it — but the complications and the skilled services they require must be documented by physicians' orders and nursing or therapy notes.

When they tell you cover is ending

The end of Medicare cover comes with a written notice, on a standard form, at least two days before the proposed end of services. The notice must state the date cover ends, the date the patient becomes financially liable, and how to request an expedited review. It must be signed for; a refusal to sign is annotated and treated as receipt.

A reduction in services is not a termination and does not carry this notice. Fewer therapy sessions is not the same event as cover ending, and only the second one comes with the appeal described here.

1. Note the time the notice was handed over. The deadline runs from receipt.
2. Call the Quality Improvement Organization for the state by noon of the next calendar day. Writing or telephone; either is allowed.
3. Expect the facility to send you a detailed written explanation by close of business on the day the QIO tells it you have appealed.
4. Expect a decision within 72 hours of the QIO receiving the request.
5. Do not pay for the disputed days while the review runs. The facility may not bill for them until the process is finished.

If valid notice was never given, cover continues until at least two days after it is. And a facility that fails to give valid notice is itself liable for the extra days rather than the family.