Medicare Benefits Periods and Re-admittance

I recently had a client who’s wife transitioned in and out of the hospital and in and out of rehab before they came to my Oakland County Elder Care law firm office.  One of their questions and and an important issue for any family caring for a loved one with long-term care issues is what exactly will Medicare pay for?

Many people are familiar that Medicare can pay up to 100 days of care in a skilled nursing facility.  They may not know that Medicare actually only pays fully up to 20 days of care.  From 20 to 100 days of care in a skilled nursing facility is covered generally partially by Medicare, but there is a co-pay.  Quite often this co-pay is picked up by a supplemental insurance program the senior may have, for example Blue Cross Blue Shield.  Then after 100 days the senior is discharged, switches over to private pay, or switches over to Medicaid, depending on the situation.

Well, what happens if that senior exhausts their 100 days, is discharged, then is readmitted to the hospital and skilled nursing home for rehab?  Does Medicare reset?

The answer is no, Medicare does not reset until a senior is 60 days outside of  receiving benefits.  This is what is known as the “spell of illness.” A benefit period begins the first day a Medicare beneficiary enters a hospital or skilled nursing facility and ends when he or she has been receiving less than a skilled level of care, or outside a hospital or skilled nursing facility for 60 consecutive days.  Once the individual clears the 60 days, that ends the spell of illness and they can then receive Medicare benefits again to cover their skilled nursing facility coverage under a new benefit period.

As a Michigan elder law attorney, this is one of the common myths or mistakes I see in my practice is confusing how Medicare works with skilled nursing care.  I hear from clients that they have to wait 90 days, they don’t have to wait of a new spell of illness, and most people don’t understand the interaction between Medicaid  and Medicare in a skilled nursing facility environment.  Making a mistake in not understanding coverage can cost families over $10,000 in long-term care costs per month.

Castle Wealth Group Legal in Media

Send Us a Message