Including Continued Days & Restart Rules

MEDICARE 100 DAY RULES

(INCLUDING CONTINUED DAYS & RESTART RULES)

There is a 100 day benefit, during which Medicare will pay for skilled care. The first 20 days are paid by original Medicare at 100% of the cost, no matter what the cost. This may not apply to Medicare Advantage programs. The next 80 days are paid by Medicare at 80% of the cost of care and either 1) the patient’s Medicare Supplemental policy may cover the uncovered portion, or 2) there is a private co-pay, which the patient must meet.

The Medicare Supplement policy may not cover the entire 20% of the uncovered portion during the 80 day timeframe. Some policies only cover 10% of the uncovered 20% and the patient is expected to pay the other 10%. This uncovered amount may be paid by Medi-Cal, IF, the patient is qualified to receive Medi-Cal during the 80 day period.

The 100 day period, during which Medicare will pay for skilled care, is triggered by a three (3) day stay in the hospital, or acute care. That is exactly three consecutive midnights in acute care, i.e., check-in at 11:59 PM Sunday and checkout at 12:01 AM Tuesday. If the patient’s stay in the acute care facility is for any amount of time less than exactly three consecutive midnights, then the skilled care component of the Medicare program is not available to pay for rehabilitation in a Skilled Nursing Facility (SNF).

The 100 day benefit begins on the first day a patient enters the SNF and is “skillable” (able to be rehabilitated) and it will stop when any one of these events occur; 1) the patient checkouts to go home, 2) the patient is returned toacute care, or 3) the benefit is stopped by the SNF treating physician.

The 100 day period may be stopped at any time, by the SNF treating physician, if it is determined that the patient is either 1) not participating in their therapy, or 2) is no longer showing improvement and has become custodial.

The 100 day period may be continued if, after a patient checks out, they return within 30 days of their checkout date AND they have another three (3) day qualifying stay. The 100 days will restart, effective with the next countable day within the 100 day period.

That would be the next counted day inside the SNF, e.g., if the original stay in the SNF was counted as ten days because the patient checked out on the 10th day and, thereafter, the patient has a three (3) day qualifying stay and returns within 30 days of the original checkout date, then the next countable day would start with the eleventh day (11th) of the 100 day benefit. In other words, the patient has 90 days remaining in the 100 day period during which Medicare will pay for skilled care.

If a patient returns more than 60 days after the last day on which Medicare paid for either a SNF or an acute care Hospital, AND they have a new three (3) day qualifying stay AND is considered skillable, then a NEW 100 day benefit may be granted.

If a patient voluntarily returns to the SNF, at any time, after they have checked out, AND without a new three (3) day qualifying stay, then the 100 day benefitdoes not continue OR restart and the patient’s insurance, (Long-Term Care {LTC} or Medicare Supplemental), must pay for the skilled care, or the patient must privately pay for the care. Most Medicare Supplemental policies do not have a LTC component and do not pay any benefit unless Medicare is also paying a benefit.