Thanks 19:59! I will look into that link in detail tomorrow!

I wonder if the COVID SNF stay/payments were under the waiver but then maybe additional paperwork wasn't done to continue the new benefit period: https://www.ahcancal.org/Survey-Regulatory-Legal/Emergency-Preparedness/Documents/COVID19/3-Day%20Waiver%20FAQ.pdf

Speculation and I didn't fully read to know how it all works, but perhaps looking into because I don't think the original benefit period ends based on 60 days without Medicare payment. It ends based on level of care, and if he's been private paying for skilled nursing then he still was at SNF level of care (if I'm following the timeline correctly in that he never left that level of care).

OP here. Medicare did pay for the Covid SNF time. It's weird bc they paid more than they were billed, according to the medicare website.

Are you sure Medicare Part A actually paid for the COVID SNF time? Vs. just being billed?

OP once again, sorry, typo above, he got hospitalized again a few weeks AFTER the covid, not "earlier."
Too sleepy, too busy trying to type "hospitalization" correctly after only one cup of coffee.

OP again, thanks I will call the SHIP.
I haven't gotten a written reason for the denial of the first, quick appeal, and the rules for quick appeals don't seem to promise me one.
It looks like the facility should have explained their reasons to me in writing, but the first appeal happened over a weekend when the business office was closed.

OP here -- thanks - let's leave tricare out of it.
He was in the snf self-pay at least October-February, and then he got covid in february and the snf put him on a different floor there for a couple of weeks for covid treatment and isolation. They billed that as inpatient time under Medicare Part A and then sent him back to his self-pay room, but he got hospitalized a few weeks earlier.
I know for a new medicare period to begin you are supposed to have been out of a snf or hospital for 60 days, but i think (?) that means Medicare has not been paying for a snf or hospital for 60 days. Otherwise the facility couldn't have started billing again under Part A when he got covid, right?
I do understand that Medicare won't pay for long term skilled nursing or for any custodial care -- I just think the recent hospitalization made him qualified for another 100 days of skilled nursing at the snf under Medicare Part A.

Another issue is why did Tricare stop paying? Are you sure Tricare was billed for October and later? I can't tell if October and following was medically necessary or not. What did Tricare say about it?

Anonymous wrote:Also I can't completely follow the story. Was the "COVID floor" at the SNF or at the actual hospital? I could be worth, but I think 3-day inpatient stay means inpatient hospital.

Supposed to be, "I could be wrong...."

Also I can't completely follow the story. Was the "COVID floor" at the SNF or at the actual hospital? I could be worth, but I think 3-day inpatient stay means inpatient hospital.

Did you read: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08pdf.pdf

I think the key is to get the Medicare paperwork that (presumably) has the reason for the denial. You can't appeal it if you don't know exactly why it was denied in Medicare's view. A PP listed some possible reasons. I would not rely on the CCRC to interpret the denial. I would want to see it myself.

Anonymous wrote:a couple thoughts:

Medicare "benefit periods":

- benefit period begins the day the patient is admitted to the hospital; they must stay inpatient at the hospital at least 3 days in order for SNF care to be paid for.

- benefit period ends whet patient hasn't been in hospital or SNF for 60 days.


Once the 60 days are up, a new benfit period can be triggered by a new hospitalization of over 3 days.

I am not sure from reading your timeline, but it sounds like your dad was readmitted to the hospital while he was still in a SNF, right? So he can't start a new benefit period so subsequent SNF won't be covered.

https://www.agingcare.com/articles/medicare-coverage-of-skilled-nursing-facility-153265.htm

A geriatric care manager might be able to help you sort this stuff out.

You are asking for long term care. Medicare only pays for limited care and there are limits to it. Dad has to pay for long term or go on medicaid. Tricare doesn't pay for long term nursing either and acts as a secondary insurance/supplement to medicare.

a couple thoughts:

Medicare "benefit periods":

- benefit period begins the day the patient is admitted to the hospital; they must stay inpatient at the hospital at least 3 days in order for SNF care to be paid for.

- benefit period ends whet patient hasn't been in hospital or SNF for 60 days.


Once the 60 days are up, a new benfit period can be triggered by a new hospitalization of over 3 days.

I am not sure from reading your timeline, but it sounds like your dad was readmitted to the hospital while he was still in a SNF, right? So he can't start a new benefit period so subsequent SNF won't be covered.

https://www.agingcare.com/articles/medicare-coverage-of-skilled-nursing-facility-153265.htm

A geriatric care manager might be able to help you sort this stuff out.

This is so complicated that I can’t follow, and I’ve read it a few times. Have u tried calling Senior Health Insurance Assistance (SHIP)? They offer counseling to people with Medicare and their families. Their hotline is (877) 839-2675 and I think they have offices in local nursing facilities.

www.shiptacenter.org

Dear Midlife Concerns Forum,
First, a big thank you to this forum group for not having as much of that snark that seems to have taken over the other DCUM forums.
I've read a lot but I still do not understand how long Medicare Part A coverage should pay for a snf stay after a repeat hospitalization. Everyone seems to think the way the system "really" works in real life is different from what the Medicare regs say.
Parents have Medicare and Tricare For Life, live in a nice continuing care community in TN. When they moved there they had to pay in advance for 360 days of snf care.
As the pandemic began, dad developed sepsis from an open would from a skin cancer surgery. Management of CHF was a big part of the hospitalization. Got discharged and went to snf bed in complex where he lives. Facility billed him for 100 days of post-hospitalization snf care, which was covered by Medicare w Tricare helping, and then Tricare paid for several more months of snf care, ending last September.
At this point I accepted at face value the facility’s explanation that Medicare would only pay for “skilled nursing” while OT and PT were making sufficient progress to justify 5 day per week service. Now I have read about the Jummo settlement where CMS agreed the need for PT/OT depends on the patient’s need for skilled services, which may be simply to avoid decline rather than continued progress.
Dad used his prepaid days until year end, then resumed using prepaid days in 2021. While using the prepaid days he was getting skilled nursing every day due to his need for close monitoring of fluid levels, constant adjustment of diuretics, pressure injuries, arthritis and gout. Wheelchair bound. Got PT/Ot a few times a week and was supposed to get non-skilled movement care on other days but short staffing due to covid made that not happen.
He got covid from a caregiver in February and they moved him to the covid floor and declared he was in “skilled nursing” care for a couple of weeks. Snf billed Medicare for this as “inpatient.” We are not yet 100 days past that date, even if it should have started a new 100 day period (should it have?).
He moved back to regular room, using prepaid days, much weaker.
Hospitalized in March due to mysterious injury on leg that became giant hematoma requiring surgery. More tricky management of heart and kidney issues.
Discharged; given snf care with Medicare billed for several weeks, then facility said they had to stop billing Medicare bc he no longer needed skilled nursing because he had plateaued in PT and OT. Ridiculous– he needs skilled nursing to watch his fluid levels and has been getting it all along, and he needs daily PT/OT with professionals to maintain his poor health, and he has a stage 4 wound.
We just appealed the initial notice of Medicare noncoverage and lost. Now we can appeal again. Would it help to have his private practice doctors write a letter about his need for skilled nursing care? The doctor at the snf described his condition accurately, although she didn’t say in so many words that he needs continued skilled nursing care.
I’ve read about Medicare changing the billing for PT/OT from RUT hourly to a balanced formula that makes Part A therapy bring in less money for facilities. I’ve read about Medicare extending the 100 day period of coverage if covid caused delays. I’ve read the Medicare manuals and the Jummo documentation. I just don’t get the big picture, common sense side of this. I know Medicare won’t pay more than 100 days after hospital discharge, but why can’t they pay those 100 days? I basically trust the people working at the facility and I think they are being straight with me, but are they just wrong about Medicare coverage?
Thanks!