I’ve told you about the 60-day rule. There is also a 30-day rule. Who knew?

30days

I tell you – I learn something every day on this job.  Today’s lesson is about Medicare’s 30-day rule. I tell you this so you don’t have to endure the additional stress I did when my father was rushed to the hospital from his skilled nursing facility when he started to bleed internally. I was not only worried about my father but also whether he had just screwed up the 100 days of skilled nursing eligibility with Medicare he had qualified for with this recent hip surgery.

The typical eligibility rules state that you must be “out of the system” (meaning healthy) for 60 consecutive days in order for an incident to re-set the clock making a patient eligible for another 100 days of skilled nursing care.  My father had been healthy for 61 days.

He was getting skilled care when he started bleeding internally and was rushed back to the hospital after only 10 days of skilled care.  Normally, in order to be Medicare eligible for skilled services, a patient has to be in the hospital for 3 days (admitted, not just under observation) before you are eligible for Medicare.  I was stressed because I didn’t know whether he would be there for 3 days and if he wasn’t, I was worried that he wouldn’t be eligible for skilled services after he was released because he went back into the hospital. And he certainly wasn’t walking yet.

HERE’S HOW IT WORKS

If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay. BUT….if you go back into the hospital within that 30 days period, the skilled care just continues on from where you left off – no need for a new hospital stay. Knowing that would have relieved that element of stress I was experiencing.

As it turned out, my dad was in the hospital for 3 nights, 2 of which were in the ICU.  He had lost 25% of his blood in one day from an ulcer in his small intestine that had been aggravated by the blood thinners which are routinely given after hip surgery (to prevent blood clots from forming).

Happy to say, he is out of the hospital and back into rehab.  My only disappointment was that I was not able to send him back to the same skilled nursing facility he had been at, which, in my opinion, was top notch.  In my next blog post, I will talk about what I wish I had done and could have done to avoid having to move him to yet another new environment….if I only had a crystal ball.

Please share this important information with your friends and family.  You never know when you will need it.  It is good info to file away in the back of your mind.  Because someday, we will all have the privilege of growing old.

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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.

Sometimes it feels like you’ve been down this road before

My father fell in mid-June and fractured his pelvis.  On Sunday, he fell and broke his hip.  The good thing about this fall (is there a good thing?) is that I feel experienced.  I know can draw on the experience I had dealing with the first fall, to navigate through the system on this fall.  I say “system” because there is one.  And it’s a very clear process to everyone who works in the health care biz.  Unfortunately, those of us on the outside get blind sighted by it the first time we are confronted with it.

What happens is this:

1) you arrive at the hospital, assumably by ambulance.  You get your parent checked in; give the all the necessary insurance cards and the like.

FIRST TIME THROUGH: They ask you for living will, advance directives, DNR documents (stands for “do not resuscitate”),  You scramble to find them, and ultimately give the documents to the hospital on day 3.

SECOND TIME THROUGH:  On the way to the hospital, you swing by the house to pick up the file you already have put together with all this documentation, so you are ready.

Next, a social worker comes into the room (before your parent even goes into surgery) to ask you where you would like your parent discharged to…as in which skilled nursing facility for rehab.

FIRST TIME THROUGH:  You panic, as you have NO idea about skilled nursing, what it is, which one is good, what you want to be asking about a facility, NOTHING.

SECOND TIME THROUGH: You have already asked your sibling to go to www.medicare.gov and look at the nursing home compare tool to look at ratings for the nursing homes within a certain mile radius of where you live.  He emails that to you, and you have it before the social worker even makes first contact.  You are ready.

What you are never ready for is when the anesthesiologist asks you whether you want your father to be resuscitated should he go into cardiac arrest while on the operating table.  That is the conversation everyone dreads, but it is necessary to have that conversation and to be ready for it.  When it came, I was frozen.  I knew my dad was very clear in his advance directives that he didn’t want anything done to prolong his life if there was no way to recover.  Putting a breathing tube down his throat during surgery because he was fading, was, in fact life-prolonging, however I decided that in the controlled environment of the OR, if something unexpected happened, I did want them to do what they could to save him.

I also made it clear that OUTSIDE the controlled environment of the operating room, my dad’s advance directive was to be respected.  So if, after surgery, for some reason my father could not breathe on his own, they were to remove it.

IMG_6316 (1)SIGH. Welcome to the club no one asks to join.  If you are a member of this club, the more prepared you can become, the less stress you will have.