Ask Diane: Does a resident ever requalify for another 100 Medicare benefit days?

By: January 8th, 2010 Email This Post Print This Post

Q:  In regards to the 60-day spell of wellness, if a resident is in a nursing facility and utilized all 100 Medicare Part A benefit days and, due to the nature of the diagnosis, had a Gastric Peg in place, will that resident ever qualify for another 100 Medicare Part A benefit days if he or she enters into a hospital again for an entirely different diagnosis well after the 60 wellness days have elapsed?

Some have said that as long as the tube is still in place, the resident cannot start a 60-day period wellness. But if a resident falls and fractures a hip four months later and has a three-day qualifying hospital stay, and can be skilled for therapy, nursing, etc., would the resident have Medicare Part A benefits or are they exhausted forever?

Diane: The definition of a skilled tube is tied to the amount of calories and percent of fluids going through the tube (26% of the calories and a minimum of 501 mls of fluid or 51% of the calories). As long as the calorie and/or percent of fluid requirements are met, the patient will not generate a new benefit period. The 60 consecutive wellness days cannot begin if the patient is receiving any skilled service. If the patient has used all 100 days, it is the responsibility of the facility to submit a benefits exhaust claim to CMS in order to prevent the common working file from generating a new benefit period. A new diagnosis does not change this scenario.

Comments

By Emma Brisbin R.N. on January 8th, 2010 at 4:52 pm

Does the above also relates/applies to residents that receives routine Nebs, Dialysis, O2, Trach care etc.? as these are considered skilled services. As well as PartB therapy services?

By Georgie True, RNAC on January 9th, 2010 at 12:55 pm

Diane, if a resident goes home with the skilled amount of tube feeding and is cared for exclusively by non-health care related family members. Are they still considered getting skilled care and if they fell, broke a hip, and went to a SNF would they get their 100 days for the hip care? Thank you

By Vanessa Lemley, RN, MDS Coordinator on January 11th, 2010 at 11:13 am

We are wondering the same scenarios as Emma Brisbin and George True. Please include us in the response to them.

By Jean Ross, RNAC on January 12th, 2010 at 7:47 am

I also wanted to ask the same questions as Emma Brisbin and George True. What if the resident is alert, oriented and totally independent with his/her tube feedings and peg care? Would that person be considered to be receiving skilled care?

By Diane Brown on January 22nd, 2010 at 1:10 pm

If the resident is discharged to home and there are 60 consecutive days between the discharge and readmission to the hospital, the spell of illness will be broken and the patient will qualify for a new benefit period.

However, if the admission to the hospital occurs prior to the lapse of 60 days, then the resident will not qualify for a new spell of illnes, but could use any remaining days left over in the prior spell of illness if the beneficiary did not use all 100 days. Otherwise, the patient would not be covered under Medicare Part A.

By Terry Walczak on February 1st, 2010 at 10:48 am

My mom was in the hospital from late October for a month, and transferred to a sub-acute facility. She was recently hospitalized for a week, and is now back in the sub-acute facility. How many sub-acute facility days would she have remaining? Does the hospital stay count for something different than the sub-acute days? I’m just confused by how medicare and supplemental benefits cover days in these types of situations.

Thank you!

By Vanessa Lemley, RN, MDS Coordinator on March 22nd, 2010 at 9:13 am

I am still needing the answer relating to the original comment submitted by Emma Brisbin R.N. on January 8th, 2010 at 4:52 pm Thank you

By Anthony Ridley LVN on March 31st, 2010 at 1:41 am

If a patient can be stabile at home on a PEG tube, why can’t they be stabile at SNF? If you did not exhaust the 100 days and moved the patient to custodial level around day 65 of the 100 days, then the patient was off skilled care for 60+ days, after which she had a new onset of illness unrelated to the PEG tube with a resulting 3+ day stay at the acute, once she is transferred back to SNF, wouldn’t she generate a new benefit period?

By Anthony Ridley LVN on March 31st, 2010 at 1:44 am

As I understand it, enteral feeding alone should not qualify a patient to be on a skilled level of care. Is this correct?

By Tony Stevens on June 8th, 2010 at 12:15 am

My father came down wih Dermatomyositis. He was hospitalized and went into a skilled nursing facitily for the maximum 100 days. He is back home and being cared for by our mother and medicare provided physical, occupational and speech therapist. After 60 days of being at home, will he qualify for another 100 days under medicare? He is in a wheelchair, needs 24 hour assistance and has a feeding tube for nutrition (unable to swallow). Thanks for any information.

By bruce Stelzer on November 17th, 2010 at 11:47 am

Diane, Did you ever respond to Emma Brisbin’s question above regarding breaking a spell of illness in a snf while receiving routing dialysis?
Thanks for your help, Bruce

I have a question. If a resident exhaust their 100 days under Med A . Then they are picked up under Med B program 5x/wk this would interfer with their 60 day wellness period right? But if they are seen 1-4 x/wk under Med B program , that isnt a daily skillable service and would not interfer with their wellness period and they could be picked back up med A if a 3 day stay ? right ?

regarding the first thread of these questions: Resident is PEG, in SNF for 3 yrs with PEG, used 100 Medicare days for 11/09-3/10, and is now hospitalized form 2/2011-3/2011, with a new diagnosis of Respiratory Failure, and on a VENT/TRACH–and now comes back to SNF with all of the above, does the resident get a new 100 days because of the new diagnosis?

By lisa Carmichael on January 26th, 2013 at 1:30 pm

If a resident was cut from medicare on day 10 of his 100 day benefit while in a snf b/c did not meet skilled criteria. Can he picked back up under the same benefit period if he was readmitted to the hospital for 4 days but did not have a 60 day wellness period?

When a resident in a long term care facility has a feeding tube Medicare would not cover them because the facility is receiving a high reimbursement rate due to the tube. Now if they are able to have the tube removed and are there for short term and it is a new tube and that is why they are admitted, they could be skilled for a related diagnosis such as Aphagia, absence of swallowing or dysphagia, difficulty swallowing then there may be a chance. As long as they had just had it placed they can still use their 100 days. But the way to get the next 100 days after a 60 day wellness period, is to not be on a skilled reimbursement rate and not be hospitalized for 60 days after they discharge from skilled services through Medicare. The problem with feeding tubes is that the resident is going to be always on skilled services once they have a peg tube. They will not have a 60 day period of health. Unless of course the tube is short term and removed. Once removed they will have to wait 60 days to qualify for 100 days of benefits.

Lisa, as long as it has been less than 30 days from the time he was discharged from skilled services, he could be picked back up on day 11 with a new diagnosis.

if a pt exhausted medicare as a new dialysis pt and went on for 60 additionally skilled days with Tricare for life for therapy. (tx discharged and ended skilled date) The pt remains in snf getting out pt dialysis.
Can the pt return to Part A in the snf 5 months later for a new qualifying hospital stay?

Does a 2 week stay in an in-hospital rehab facility break the 60 day wellness period?

STROKE PT USES 100 MC DAYS IN SKILLED NURSING FACILITY. AFTER THE 60 DAYS OF WELLNESS, A NEW HOSPITAL STAY FOR KIDNEY INFECTION, COULD PT AGAIN QUALIFY FOR THE 100 DAYS OF MC IN SKILLED FACALITY?

 

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