Ask Diane: Does a spell of wellness end with observation time in a hospital?
Q: I have a question regarding the 60-day spell of wellness and Medicare. We are admitting a patient today that used 100 days of Medicare skilled days earlier this year at a SNF. He went home from the SNF and stayed for 58 days. Then he went to the hospital and was put in an observation bed for 2 days, being admitted on day 3. I am being told that he is eligible for a new 100 days of skilled benefits because he was not admitted to the hospital until day 61. However, I feel that the spell of wellness ended when he was brought to the hospital for an acute episode. Additionally, I thought that observation time was converted to inpatient days if later admitted, as in this case. Can you please clarify this for me?
Diane: Section 10.4.3 of the Medicare General Information, Eligibility and Entitlement Manual states that “a benefit period cannot end while a beneficiary is an inpatient of a hospital, even if the hospital does not meet all of the requirements that are necessary for starting a benefit period. Similarly, a benefit period cannot end while a beneficiary is an inpatient of a SNF, as defined below.” It also notes that “If day 61 turns out to be the official day of admission to the hospital and the patient has the required 3-day hosp stay and is admitted to a SNF within 30 days of the hospital stay, then the patient is entitled to a new 100 day benefit period. If, on the other hand, the hospital uses day 58 as the official date of admission, then the beneficiary does not qualify for a new benefit period and the 60 days of wellness must start all over again.”
However, the regulation refers to the ‘official day of admission’ and does not address observation time in the hospital. Therefore, the answer to your question is not clear cut. I would recommend contacting a representative from CMS or asking your question at the next SNF open door forum, which will be held on August 27, at 2pm eastern time. I will continue to look into this issue and let you know if I find any information. Thanks.
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Diane Brown
Diane Brown is a long-term care regulatory specialist and lead educator for HCPro's MDS 3.0 Boot Camp and Medicare Boot Camp-Long-Term Care Version. She is also a long-term care consultant with over 25 years of operational experience in healthcare. For Diane's complete bio, visit the About page.
Diane has written 240 posts.
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Comments
I think this situation is clear. The beneficiary is entitled to a new benefit.
I would think that if the hospital stay resulted in an admission, the 1st day of the observationsl period would be looked at as the 1st day of their hospital stay, and having received skilled care. In this situation, it occurred before the 60th day, therefore this person would not recoup the 100 days at this time.Am I right?
In this situation, if the first day of the observation period is considered the official day of admission to the hospital, the individual would not qualify for a new 100-day benefit period as he would have been admitted on day 58. Therefore, he would not meet the required 60-day period of wellness. However, if the individual is officialy admitted to the hospital the day after the 2-day observation period (on day 61), he would qualify for a new 100-day benefit period.
Would a visit to the ER interupt the 60 day rule? I have been told both that it does and doesn’t.
In regards to the 60 day spell of illness. If a resident is a in a nursing facility and utilized all 100 Medicare Benefit days and due to the nature of the diagnosis, had a Gastric Peg in place and that is what utilized the 100 days, does a resident then “ever” qualify for another Medicare 100 beneficiary days if he or she enters into a hospital again for an entire different diagnosis well after the 60 wellness days have elapsed. Some have said that since the tube is still in place, there is will never be a break for a 60 day wellness. But is a resident falls and fractures 4 months later and has a 3 day qualifying stay, and can be skilled for Therapy, nursing, etc., would they have Medicare benefits or is it a exhausted forever.
Some have said exhausted forever.
Thank you
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