Ask the Experts, MDS 3.0 Items, Payment/economy, Regulations

Ask the expert: Benefit periods

Q: A Medicare member benefits exhausted, but has been receiving a regular dose of insulin in the morning and night. Member went to the hospital, and is now returning to a facility, where she is a long-term resident. Would she regenerate a new benefit for Part A coverage? It has been more than 60 days since benefits exhaust, but she has still been receiving the insulin.

A: The question is not whether the patient is receiving a regular dose of insulin, that in and of itself is not considered skilled care, but whether it rises to the level of skilled care.  If there are new orders for insulin frequently and the patient requires some special monitoring for instability (e.g., if they have a surgical procedure or an infection), then you may have skilled care.

If your patient was not receiving skilled care for more than 60 days after the benefits exhausted and the patient was not hospitalized during that time, then the patient should have generated a new benefit period. If the patient meets the Medicare pre-admission requirements (Three-day qualifying stay and admitted to the SNF within 30 days) and has orders for skilled care, then she could be admitted to skilled care under Part A.