Case Flash:  No Appeal Rights if SNF Benefit Period Exhausted

Mrs. D is enrolled in Original Medicare. Three months ago, she needed cardiac surgery and was admitted to the hospital for the operation. When Mrs. D was discharged, she was transferred to a Medicare-certified skilled nursing facility (SNF) to receive skilled nursing and occupational therapy. Mrs. D was about to reach the 100-day limit of Medicare’s SNF benefit period. Her daughter recently spoke to Mrs. D’s doctor, who said while Mrs. D could benefit from further physical and occupational therapy in the SNF, it was safe for her to return home and receive therapy there. If she wanted to stay in the SNF, Mrs. D would need to pay for her care herself.

Laura called the Medicare Rights Center and relayed the situation to a hotline counselor. She explained that neither she nor Mrs. D could afford to pay for the entire cost for the SNF. She asked whether they could appeal for more Medicare SNF coverage. The hotline counselor explained that when you exhaust the Medicare benefit period, you do not have these the usual notice and appeal rights.

The counselor then asked Laura whether she had considered the possibility of her mother getting care at home. Laura said she thought Medicare did not pay for home health services. The counselor explained that Medicare may pay for a home health aide under Medicare’s home health care benefit if you need skilled care (such as skilled nursing or skilled therapy services). Medicare would also pay for some personal care in this situation.

To qualify for Medicare coverage of home health care, Mrs. D’s doctor would first need to certify that she was homebound (meaning that it would take considerable and taxing effort for her to leave home) and needed skilled care. Mrs. D’s SNF could then refer her to a Medicare-certified home health agency (HHA). Depending on the amount of care the HHA determines Mrs. D will need, Medicare would pay for up to 35 hours a week of care at home (although usually much less). The next day, Laura talked with her mother’s doctor and the social worker at the SNF. Together, they arranged for Mrs. D to stay in the SNF until the end of her Medicare benefit period and then return home, where she would receive her care from a Medicare-certified HHA.

-From:  “ Case Flash: Options for Care After Exhausting a SNF Benefit Period”, Medicare Watch, a biweekly electronic newsletter of the Medicare Rights Center, Vol. 12 , No. 5: March 11, 2009.

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