Medicare Explained: The Skilled Benefit Period

I wrote in an earlier post about the required hospital stay that will qualify a Medicare patient to access their Part A benefit to cover a skilled nursing (post hospital and/or rehabilitation) stay (check out ‘Midnight Madness Medicare Style’).  This is only a small part of understanding the criteria for accessing a benefit period.

(….now the dry part….I will try to end with some light commentary at the other end….)

Additional qualifications must also be met.  Some of them are:  a physician must confirm the need for daily skilled nursing/rehabilitation service; the patient must be admitted to a Medicare certified bed; the daily skilled services must be related to the treatment that the patient received in the hospital; as a practical matter, the daily services that are required can only be provided in a skilled nursing/rehabilitation facility (and not in the home); the admission to a skilled nursing facility must occur within 30 days of the discharge from the qualifying hospital stay.

If the Medicare patient meets the qualifying criteria, they can access the benefit period.  Let me caution you a bit about those ‘100 days’.

While the full benefit is for a 100 day period, please understand that the patient must continue to meet specific Medicare guidelines to continue accessing those days to the 100th day.  It is not automatically guaranteed.

If the patient reaches a point of improvement in their medical condition that removes them from a ‘qualifying’ category (a whole other topic!), or the patient has reached their maximum improvement in therapy (or is consistently refusing participation in therapy) the Part A covered stay could come to an end before the entire 100 days have been used.  The patient/family must be notified 48 hours prior to Medicare coverage being discontinued (to let you know what the ‘last covered day’ will be) and you do reserve the right to appeal the decision (if there are benefit days remaining).

KEY POINT:  Just because you qualify to access the 100 day benefit period does not guarantee you the full 100 days.  You must continue to meet certain qualification guidelines throughout the benefit period.

(Deep breath………we’re almost done……)

As an example, my father, who did get his qualifying hospital stay at Christmas time, was placed in a skilled nursing facility for rehabilitation.  He received Physical Therapy, Occupational Therapy and Speech Therapy for about 6 weeks.  At that point, though he had not used 100 days of his benefit period, he no longer was receiving services that qualified him under Medicare.  My mother was notified by the facility before the Medicare benefits ended.  He continues to stay in this facility as a resident but now pays privately for his care.  Due to the nature of his needs, he will also qualify to access his long-term care benefits after reaching the 100 day exclusion period.

It has been my observation that most Medicare recipients and their families (including my own!) do not fully understand how these benefits work.  This is only a very small piece of this very complex process.  If you find yourself in this predicament, I encourage you to seek out somebody who has a good understanding to help guide you through this new territory.  You can also access information at www.medicare.gov.  Being educated about Medicare will provide you with some understanding about what is happening if and when your loved one is in this situation.  And knowing what to anticipate really does alleviate some of the stress.

OK, I feel your pain….but think about how the government has wrangled with insurance and Medicare issues for years!  After all of those years and certainly thousands of pages of legislation, how could we expect it to be simple??  If you are thinking that this doesn’t matter to you, let me remind you that having an understanding of the qualifying criteria and the process saved my family big money!  And if for no other reason than that, you should want to know…….

Now, please go find a way to relax after all of that!

On the journey with you…….Kathy

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