You do not have to improve to qualify!
Coverage Criteria
3-Day Inpatient Hospital Stay
1.
You must have a qualifying three-day inpatient (as
opposed to outpatient) hospital stay. Medicare Advantage plans might not
have this requirement.
2.
Generally, a transfer to a skilled nursing
facility must be made within 30 days of leaving the hospital.
Physician’s Order
1.
Your care at the skilled nursing facility must
have been ordered by a physician and must relate to a condition for which you
received inpatient hospital services or that arose at the skilled nursing
facility while being treated for a condition for which you received inpatient
hospital services.
2.
As a practical matter, the care must only be available
on an inpatient basis.
Daily Skilled Care
1.
You must require and receive skilled nursing
seven days a week, skilled therapy five days a week, or a combination of both skilled
nursing and therapy services seven days a week.
2.
Skilled care means that services must be
provided by, or under the supervision of, a skilled professional in order to be
safe and effective.
No Improvement Standard
1.
Medicare coverage “does not turn on the presence
or absence of a beneficiary’s potential for improvement, but rather on the
beneficiary’s need for skilled care. Skilled care may be necessary to improve a
patient’s condition, to maintain a patient’s current condition, or to prevent
or slow further deterioration of the patient’s condition.” CMS
Transmittal 179, Pub 100-02, 1/14/2014; Medicare Benefit Policy Manual,
Chapter 8, Sections 30.2, 30.3.
100-Day Benefit Period
1.
Your maximum benefit period is 100 days. It is
possible to have more than one benefit period during the calendar year.
2.
You are entitled to
notice and to file an appeal when your Medicare-covered skilled nursing
facility care is terminated before the end of your benefit period.
For additional information, see the Center for Medicare Advocacy’s Improvement
Standard Homepage.
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