Winston Law Group
Winston Law Group

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Maintaining Medicare Skilled Nursing Facility Coverage

Following a hospital inpatient stay of at least three days, Medicare will pay for care in a skilled nursing facility (SNF) for up to 100 days for each period of coverage. This is often called “rehabilitation” coverage and can be provided in a dedicated rehabilitation facility, certain parts of some hospitals, or in some facilities that also provide nursing home care. The purpose of this type of care is to transition the patient back to as much an independent level of self-care as possible.

When does coverage end?

Formally, Medicare rehabilitation coverage would end when the patient no longer showed “improvement,” regardless of remaining days of coverage. Under a recent court settlement agreement called Jimmo v. Sibelius brought by some elder law advocates against the Medicare agency, the agency has issued new instructions stating that it has “clarified” how its former policy was being applied. The policy now states that “when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration.” In effect, this will allow many patients to remain in the SNF under Medicare coverage for longer periods of time before coverage ends.

What happens when coverage ends?

However, what happens when the patient receives notice that Medicare SNF coverage is finally ending, and that it must private pay or leave?  One solution is to exercise the right to a Medicare expedited appeal and obtain a physician recommendation for continued daily care.  While easier said than done, health and independence are worth fighting for. To succeed, it’s important to know your rights, what to watch for, and how to respond.

First of all, before a reduction in care can take effect, the skilled nursing facility is required to provide a standard notice at least two days prior to the end of care. This notice will tell you the date coverage will end, the date the patient’s financial liability begins, and the phone number to contact for an expedited appeal to overturn this decision.

The catch is you have until noon the day after receipt of this notice to appeal the reduction in care or you lose the right to an appeal. The burden is on you to watch for this notice and respond immediately. Remember, the facility must give you the notice, but they don’t have to draw your attention to it. All too often, these notices are quietly left at the beneficiary’s bedside or slipped into a pile of paperwork. If you don’t know your rights and watch for the notice, you can easily miss the appeals window.

While the appeal process is time consuming and tedious, the ultimate goal of rehabilitation and independent living is worth the effort. Our hope is that your awareness, diligence and perseverance will prevail, and we are here to lend support anytime you need it.

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