A Rehabilitation "Gotcha"
When 100 Days Isn't 100 Days

When her mother had a stroke Sandy didn't know the first thing about Medicare defined benefits and "Rehabilitation Days." Because she had never heard the terms and didn't know how the system works she may have made some costly mistakes when her mother was discharged from the hospital to a skilled nursing facility for rehabilitation.

What Sandy discovered about how Medicare counts hospital days and benefit periods was important, because it had a direct impact on how much treatment her mother would be entitled to. The potential impact of Medicare rules needed to be taken into account when Sandy made plans for her mother's care.

Edith, Sandy's mother, spent a several days in the hospital after her stroke. The therapists then recommended that Edith move to a skilled nursing facility for more therapy. Edith was improving, but she needed more rehabilitation.

Edith had a good secondary insurance policy, so Sandy wasn't worried about her mother's rehabilitation being covered. She knew Medicare would cover up to a maximum of 100 days of inpatient therapy. When the rehab center said they were ready to send Edith home, Sandy advocated tirelessly for her mother to be allowed to continue therapy. Sandy ultimately convinced the center to keep Edith several more weeks.

A little more than nine weeks after what would have been her original rehabilitation discharge date Edith had a set-back when she fell at the rehab center. She suffered a hairline fracture of her hip and went back to the hospital for a few days.

Even though this second time in the hospital was for a brand new medical problem Edith hadn't been out of the hospital and rehab for 60 consecutive days, so her re-hospitalization was considered to be a continuation of her first stay. After this second hospital stay Edith could probably have gone directly home, but Sandy again advocated strongly for what she thought her mother needed, and Edith returned to the rehab center for more physical therapy.

She is still unstable when she walks and needs to be watched closely so she doesn't fall again. She has now used up almost of her 100 maximum allowable rehabilitation days. She is still in her first Hospital Benefit Period because she has not been out of the hospital or rehabilitation facility for at least 60 consecutive days.

Now some hard decisions have to be made. Edith could stay on in the skilled nursing center for another week or two to take advantage of all the therapy she can get. That might make all the difference in preventing another fall. But that would also use up all of Edith's remaining rehabilitation days. Or, she could go home and begin working on the 60 days she has to remain out of a medical facility. She could try to re-set her eligibility clock at home and keep those few remaining days available, just in case.

Whatever Sandy decides for her mother, they will be taking a gamble.

Until Sandy finally called me she didn't completely understand that her mother's "clock" hadn't been re-set for up to 100 new days with the second hospital stay. It's unfortunate, but many hospitals and skilled nursing facilities don't do a very good job of explaining this to families until the days have been all but exhausted. And not understanding how the Medicare system really works can have serious consequences for both the patient and the family.
 

When it comes to the hospital (Medicare Part A), Medicare works by "Benefit Periods" rather than on an annual basis like most health insurance. After a hospitalization the patient must stay out of the hospital or other Medicare facility (like a rehabilitation or skilled nursing facility) for at least 60 consecutive days in order to re-set the clock and earn eligibility for a new Benefit Period.

If the patient goes back to the hospital within 60 days of being discharged from a Medicare facility (hospital or skilled nursing/ rehabilitation), it is considered to be part of the first hospital period, even if it is for a new medical problem. This has serious consequences for allowable rehabilitation days, as we saw with Edith. The second time she came out of the hospital, rather than starting fresh with another 100 potential days, as Sandy thought, she picked up her rehabilitation days where she left off.

When she has used up all of her allotted days, any additional skilled
care Edith needs outside of the hospital will have to be paid out of her own pocket until she has been out of the Medicare inpatient system for at least 60 days.

So when Sandy thought she was helping her mother by pushing to extend her stay in the rehab facility, she was using precious rehabilitation days that she could possibly have saved. Edith could have been out of the "system" for more than 60 days when she fell, and she could have had a new Benefit Period. I really fault the rehab staff for not making this clear to Sandy, but here we are.