As the cost of decent Nursing Home care in New York City steadily increases towards $20,000 per month, families must remain vigilant and proactive in the medical treatment of their loved ones who are on Medicare during a hospital stay. Medicare will pay for skilled care and rehabilitation in a Skilled Nursing Facility for up to 100 days. However, in order to qualify for this coverage, Medicare beneficiaries must enter a facility within 30 days of a qualifying hospital stay, which requires inpatient treatment for at least three consecutive days. Medicare will pay the cost of the first 20 days and part of the cost of the next 80 days as long as they deem it medically necessary. It is always important to ask if the patient has been formally admitted to the hospital. If he or she has not been admitted and is being held in the hospital under Observation Status, the patient is covered by Medicare Part B Outpatient coverage only and the visit does not count as a qualifying stay. A patient is under Observation Status when a doctor has a patient remain in the hospital so his or her condition can be monitored, but does not admit that person to the hospital as an inpatient. If the patient needs rehabilitation in a Skilled Nursing Facility within 30 days of being released from the hospital under Observation Status, Medicare will not cover the cost.
The New York Times recently reported a 69 percent increase in classifications of Observation Status for seniors entering hospitals. Starting April 1, 2014, a new Medicare regulation called The Pumpkin Rule will be enforced by Medicare officials. The Pumpkin Rule will require doctors to admit patients they anticipate will stay longer than two midnights. Those patients expected to stay for a shorter time period will be classified as Observation patients. Doctors believe that due to this rule, some patients will be admitted simply because they entered the hospital at the right time of day, and not because they have more complicated medical problems. While this rule does not alter the three day inpatient hospital stay minimum required for Skilled Nursing Facility coverage, it will impact whether the patient’s stay qualifies them for Medicare coverage of subsequent rehabilitation needed of a Skilled Nursing Facility.
Although advocacy groups continue to focus on the legal battle regarding the classification of Observation Status itself, patients and their families must continue to check their admission status and push for admission if the patient’s medical condition and risk factors require admission. This is particularly important if the patient will need rehabilitation in a Skilled Nursing Facility upon discharge. A patient or family member may seek reimbursement from Medicare for payments made to a Medicare licensed Skilled Nursing Facility by arguing that the patient should have been admitted after leaving the hospital. However, the appeals process is time-sensitive, time consuming, and can be quite cumbersome for patients and their families. Therefore, it is important to be actively involved during the hospital stay in order to save time and money.
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