Ask the Experts, Regulations

Ask the expert: Medicare coverage

Q: A resident in a SNF has not used her Medicare benefit since 2005. She was receiving rehab therapy 5x week prior to qualifying for a hospital stay. Are we allowed to skill her upon re-admission?

A: Your question cannot be answered without more information.  Did the beneficiary ever go 60 days without receiving skilled care since 2005, regardless of the insurance?

Assumption 1: Let’s assume that the resident had gone 60 days without receiving a skilled service sometime between 2005 and the new qualifying hospital stay. We will also assume the therapy being received prior to the hospitalization was covered under Medicare Part B. When this resident is readmitted the Part B would not have any effect on the Medicare Part A and the resident (provided he/she needs skilled care) would be covered under Medicare Part A.

Assumption 2: Let’s assume that the resident never satisfied the requalification requirement (60 consecutive days without a skilled service); perhaps due to a skilled service such as 100% tube fed every day. In this case, the resident would never qualify for another 100 days of Medicare Part A as the resident remains in the facility with tube feeding.