Medicare pays for the first 90 days of hospitalization for a single benefit period (either a single hospitalization or a series of hospitalizations for the same illness). 42 U.S.C. §1395d. Medicare beneficiaries are entitled to an additional 60 “lifetime reserve” days which can be used only once in a lifetime to cover any additional days.
Medicare’s coverage for skilled nursing care is quite different. A skilled nursing facility (SNF) provides skilled nursing care for ill patients who require medical or nursing care OR provides rehabilitation of injured, disabled, or sick persons as long as the care is not “primarily” for the care and treatment of mental diseases. 42 U.S.C. § 1395i-3(a). Medicare’s coverage is available for up to 100 days, as long as the patients meet the following requirements:
- hospitalization for at least three consecutive days before being admitted to the SNF. 42 C.F.R. § 409.30(a)/
- admission to the SNF within 30 days of the discharge from the hospital.
- requires skilled nursing care or rehabilitation on a daily basis that can only be provided in a SNF. (Skilled nursing must be performed daily while therapy must be performed at least five days a week.)
- obtains certification from a physician that the patient requires a SNF.
- receives care at the SNF.
Medicare covers the first twenty days and pays for all but about $140/day for days 21-100. Most supplemental health insurance plans (like Blue Cross/Blue Shield) cover that co-payment.
Many people (even in the industry) believe that coverage ceases as soon as the patient “plateaus,” i.e. as soon as the patient’s rehabilitation ceases to progress. In fact, Medicare law is explicit that continued coverage for “skilled services” at a SNF does not require that the patient have “restoration potential.” Indeed, federal regulations state that “restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.” 42 C.F.R. § 409.32(c). (Emphasis added)
Further, the Medicare Intermediary Manual states that “The repetitive services required to maintain functions sometimes involve the use of complex and sophisticated therapy procedures and, consequently, the judgment and skill of a physical therapist might be required for the safe and effective rendition of such services. The specialized knowledge and judgment of a qualified physical therapist may prevent or minimize deterioration caused by a medical condition, if the program is to be safely carried out and the treatment aims of the physician achieved. Establishing such a program is a skilled service.” § 3132.3.A.1.e (Emphasis added)
Note, also that the Medicare Intermediary Manual provides an example at § 3132.1.B: “Even where a patient’s full or partial recovery is not possible, skilled services could still be needed to prevent deterioration or to maintain current capabilities. A cancer patient, for instance, whose prognosis is terminal may require skilled services at various stages of his illness … to relieve fluid accumulation and nursing assessment and intervention to alleviate pain or prevent deterioration. The fact that there is no potential for such a patient’s recovery does not alter the character of the services and skills required for their performance.”
There is a reason why Medicare covers skilled nursing care or therapies for patients not only to improve but also to avoid regression. Other parts of Medicare regulations deal with the fact that, once a regimen is established, some patients can be treated successfully by persons who are not “skilled,” therefore breaking the chain of continued skilled care or therapies. But the Medicare Intermediary Manual recognizes the need for maintenance and the prevention of deterioration. Thus, patients who have achieved the highest level of “restoration” may still receive Medicare coverage if ending therapies is likely to lead to deterioration.
