SNF Stay and End of Benefit Period

10.4.3.2 - SNF Stay and End of Benefit Period (Rev.10880, Issued: 08-06-21, Effective: 11-08- 21, Implementation: 11-08-21 Similarly, to end a benefit period, a beneficiary cannot have been an inpatient (see §10.4.4) of a SNF for at least 60 consecutive days; where SNF is defined in accordance with §§1861(a)(2) and 1819(a)(1) of the Social Security Act as a facility which is primarily engaged in providing skilled nursing care and related services to residents who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons. As indicated above in §10.4.3, all Medicare-certified SNFs (including Medicare-certified distinct part SNFs) are automatically considered to meet this basic “SNF” definition by reason of the Medicare certification itself. See §2166 of the State Operations Manual (Pub. 100-07), Chapter 2, for the administrative criteria used in determining whether the basic “SNF” definition is met by a nursing home that is not Medicare-certified (including the noncertified portion of an institution that also contains a Medicare-certified distinct part SNF). Examples: An individual may be discharged from and readmitted to a hospital or SNF several times during a benefit period and still be in the same benefit period if 60 consecutive days have not elapsed between discharge and readmission. The stays need not be for related physical or mental conditions. Example 1: X was born 8/9/1936. On 7/28/2001, X entered a participating general hospital. After he/she had been in the hospital for 2 weeks, X was discharged on 8/11/2001. On his/her doctor’s orders, X entered a participating SNF on 8/15/2001, and remained an inpatient there (see §10.4.4) until his/her discharge on 10/27/2001. He/she had no further inpatient stays in 2001. X’s benefit period began on 8/1/2001, the first day of the month he/she attained age 65 and was entitled to hospital insurance. The benefit period ended 12/25/2001, the end of the 60-day period beginning with the date of his/her last discharge. Example 2: Y, over age 65, entered a participating general hospital on 8/28/2000 for treatment of a heart condition. He/she was discharged on 9/11/2000. On 10/3/2000, Y entered a Medicaid-only nursing facility, and remained an inpatient of this facility (see §10.4.4) until his/her discharge on 11/17/2000. On 12/26/2000, Y was again admitted to a participating hospital because of injuries suffered in an accident. He/she was discharged on 1/13/2001 and had no further inpatient stays in 2001. Y’s benefit period began on 8/28/2000. His/her stay in the nursing facility began less than 60 days after his/her hospital stay and the benefit period was continued because he/she remained an inpatient there (see §10.4.4) even though Medicare did not cover the stay. The subsequent hospital stay began less than 60 days after the nursing facility stay and continued the benefit period although the condition treated was unrelated to his/her prior stays. The benefit period ended on 3/14/2001, the end of the 60-day period beginning with the day of last discharge. Example 3: Z, over age 65 and entitled to hospital insurance benefits, was admitted to General Hospital on 8/l/2000 and discharged on 8/10/2000, having received nonemergency hospital services. General Hospital met all the requirements in the definition of a hospital except those concerning utilization review and health and safety. While General Hospital met the minimum requirements of an emergency hospital, Z’s benefit period did not begin with his/her admission to this hospital because: 1. The hospital did not meet all of the requirements in the definition of a hospital; and 2. Although the hospital satisfied the minimum requirements for coverage of emergency services, Z did not receive emergency inpatient care there. (As noted previously, a stay in an emergency hospital does not begin a benefit period unless it actually involves the receipt of covered inpatient emergency services; by contrast, even a nonemergency stay in such a hospital can serve as a qualifying hospital stay for purposes of coverage under the posthospital extended care benefit.) Z was admitted to Haven Convalescent Home on 8/20/2000 and remained an inpatient of the home (see §10.4.4) until his/her discharge on 3/1/2001. He/she had no further inpatient stays in 2001. Haven Convalescent Home became a participating SNF on 1/1/2001. Z's benefit period began 1/1/2001, the day Haven Convalescent Home was determined to be a qualified SNF. The services Z received from that date through discharge were extended care services even though they were not covered and, therefore, not charged against Z’s Medicare SNF utilization. (The services were not covered posthospital extended care services because Z was not admitted to a participating SNF within 30 days after discharge from the hospital.) Z’s benefit period ended 4/29/2001, the end of the 60- day period beginning with the date of his discharge from the convalescent home.