The Medicare 60-day rule. Critical to know.

60days

As you know, if you’ve been reading my blog, I have been working on a Medicare appeal to fight what I considered to be an early discharge from Medicare in late July when my dad was in rehab for a pelvic fracture. I had appealed twice and had lost those appeals and was about to go before an Administrative Law Judge to hear my case on November 3rd, when I learned about the 60-day rule.

IT IS VERY IMPORTANT TO KNOW ABOUT THIS RULE.

When my dad fell again at the end of September and fractured his hip, which required hip replacement surgery and another round of rehab, I assumed that Medicare would consider this a separate incident.  With each incident, I thought, a person is covered 100% for 20 days and then from day 21 until day 100, a co-pay is charged.  If you have secondary insurance, that insurance pays the co-pay.

I assumed that since this was a different body part injured and that it was injured in a completely different time frame (and in his case, a different state), that the clock would re-set and he would have another 100 days to use for his hip replacement recovery. NOT TRUE.

MEDICARE RULES STATE THAT YOU HAVE TO BE OUT OF THE SYSTEM FOR 60 CONSECUTIVE DAYS FOR THAT CLOCK TO RESET. Otherwise, they just lump the second fall into the first and you are allowed to use whatever the balance of days you have left.  In my father’s case, it would have been less than 60 days.

As I was just about to ship off my documentation to the Administrative Law Judge, I learned of this rule. Amazingly, I learned of this rule because someone posted a story on Facebook about their own parent’s circumstance in response to reading my last blog  post.  This is exactly what I envisioned when I started this blog.

I CAN HELP YOU AND YOU CAN HELP ME. Please share this blog with your friends and family.  Information is power.

I will now withdraw my appeal to Medicare for the last incident.  Fighting for that extra week in July would mean that he would have been out of the system only 54 days. If I leave things alone, he’ll have been out of the system for 61 days, and therefore eligible for the full 100 days.

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