HI 00601.130 Prior Hospitalization and Transfer Requirements
Posthospital extended care services furnished to inpatients of a skilled nursing facility (SNF) are covered under the hospital insurance program. Patients having hospital insurance coverage are entitled to have payment made on their behalf for the reasonable cost of covered extended care services furnished by an SNF or by others under arrangements with the SNF.
B. Three-day prior hospitalization
In order to qualify for posthospital extended care services, the individual must have been an inpatient of a hospital for a medically necessary stay of at least 3 consecutive calendar days. In addition, effective 12/5/80, the individual must have been transferred to a participating SNF within 30 days after discharge from the hospital, unless the exception in subsection C.2. applies.
The hospital discharge must have occurred on or after the first day of the month in which the individual attained age 65 or became entitled to health insurance benefits under the disability or chronic renal disease provisions of the law. The 3 consecutive calendar days requirement can be met by stays totaling 3 consecutive days in one or more hospitals. In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day.
To be covered, the extended care services must have been for the treatment of a condition for which the beneficiary was receiving inpatient hospital services, or a condition which arose while in the SNF for treatment of a condition for which he was previously hospitalized. In addition, the qualifying hospital stay must have been medically necessary.
The 3-day hospital stay need not be in a hospital with which the SNF has a transfer agreement. However, the hospital must be: (a) a participating general, psychiatric, or tuberculosis hospital; or (b) an institution which meets at least the requirements of an emergency services hospital.
Stays in Christian Science Sanatoriums are excluded for the purpose of satisfying the 3 day period of hospitalization. Additionally, there is a prohibition of use of waiver of liability days in meeting the 3 day requirement.
NOTE: While a 3 day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions which primarily provide psychiatric treatment cannot participate in the program as SNFs. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only noncovered care. In the SNF, the term “noncovered care” refers to any level of care which is less intensive and skilled than the SNF level of care which is covered under the program. (See HI 00601.135.)
A stay of 3 or more days in a hospital outside the United States may satisfy the prior inpatient stay requirement for post-hospital extended care services within the United States if the foreign hospital is qualified as an “emergency hospital.”
C. Thirty-day transfer
Posthospital extended care services represent an extension of care for a condition for which the individual received inpatient hospital services. Extended care services are “posthospital” if initiated within 30 days after discharge from a hospital stay which included at least 3 consecutive days of medically necessary inpatient hospital services. (In certain circumstances the 30 day period may be extended, as described in 2. below.) For SNF admissions occurring after October 29, 1972, but before December 5, 1980, see subsection 4. below.
In determining the 30 day transfer period, the day of discharge from the hospital is not counted in the 30 days. For example, a patient discharged from a hospital on August 1 and admitted to an SNF on August 31 was admitted within 30 days. The 30 day period begins on the day following actual discharge from the hospital and continues until the individual is admitted to a participating SNF, and requires and receives a covered level of care. Thus, an individual who is admitted to an SNF within 30 days after discharge from a hospital, but does not require a covered level of care until more than 30 days after such discharge, does not meet the 30 day requirement. (See 2. below for an exception under which such services may be covered.)
If an individual whose SNF stay was covered upon admission is thereafter determined not to require a covered level of care for a period of more than 30 days, payment could not be resumed for any extended care services he may subsequently require even though he has remained in the facility. Such services could not be deemed to be “posthospital” extended care services. (For exception, see 2. below.)
2. Medical appropriateness exception
An elapsed period of more than 30 days is permitted for SNF admissions where the patient's condition makes it medically inappropriate to begin an active course of treatment in an SNF within 30 days after hospital discharge, and it is medically predictable at the time of the hospital discharge that he will require covered care within a predeterminable time period. The fact that a patient enters an SNF within 30 days of discharge from a hospital, for either covered or noncovered care, does not necessarily negate coverage at a later date, assuming the subsequent covered care was medically predictable.
a. Medical needs are Predictable
In determining the type of case which this exception is designed to handle, it is necessary to recognize the intent of the extended care benefit itself. The extended care benefit covers relatively short-term care when a patient requires skilled nursing or skilled rehabilitation services as a continuation of treatment begun in the hospital. The requirement that covered extended care services be provided in an SNF within 30 days after hospital discharge is one means of assuring that the SNF care is related to the prior hospital care.
This exception to the 30 day requirement recognizes that for certain conditions SNF care can serve as a necessary and proper continuation of treatment initiated during the hospital stay, although it would be inappropriate from a medical standpoint to begin such treatment within 30 days after hospital discharge. Since the exception is intended to apply only where the SNF care constitutes a continuation of care provided in the hospital, it will be applicable only where, under accepted medical practice, the established pattern of treatment for a particular condition indicates that a covered level of SNF care will be required within a predeterminable time frame. Accordingly, to qualify for this exception it must be medically predictable at the time of hospital discharge that a covered level of SNF care will be required within a predictable period of time for the treatment of a condition for which hospital care was received and the patient must begin receiving such care within that time frame.
An example of the type of care for which this provision was designed is a hip fracture case. Under the established pattern of treatment of hip fractures it is known that skilled therapy services will be required subsequent to hospital care, and that they can normally begin within 4-6 weeks after hospital discharge, when weight bearing can be tolerated. Under the exception to the 30 day rule, the admission of a hip fracture patient to an SNF within 4-6 weeks after his hospital discharge for skilled care, which as a practical matter can only be provided on an inpatient basis by an SNF, would be considered a timely admission.
b. Medical needs are not predictable
When a patient's medical needs and the course of treatment are not predictable at the time of hospital discharge because the exact pattern of care which he will require and the time frame in which it will be required is dependent on the developing nature of his condition, his admission to an SNF more than 30 days after discharge from the hospital could not be justified under this exception to the 30-day rule. For example, in some situations the prognosis for a patient diagnosed as having cancer is such that it can reasonably be expected that he will require additional care at some time in the future. However, at the time of his discharge from the hospital it is difficult to predict the actual services which will be required or the time frame in which the care will be needed. Similarly it is not known in what setting any future necessary services will be required; i.e., whether he will require the life-supporting services found only in the hospital setting, the type of care covered in an SNF, the intermittent type of care which can be provided by a home health agency, or custodial care which may be provided either in a nursing home or his place of residence. In some instances such patients may require care immediately and continuously; others may not require any skilled care for much longer periods, perhaps measured in years. Since in such cases it is not medically predictable at the time of the hospital discharge that the individual will require covered SNF care within a predeterminable time frame, such cases do not fall within the 30-day exception.
c. SNF stay prior to beginning of deferred covered treatment
In some cases where it is medically predictable that a patient will require a covered level of SNF care within a predeterminable time frame, the individual will also have a need for a covered level of SNF care within 30 days of hospital discharge. In such situations, this need for covered SNF care does not negate further coverage at a future date even if there is a noncovered interval of more than 30 days between the two stays, provided all other requirements are met. (See example no. 1 below.) However, this rule applies only where part of the care required involves deferred care which was medically predictable at the time of hospital discharge. If the deferred care is not medically predictable at the time of hospital discharge, then coverage may not be extended to include SNF care following an interval of more than 30 days of noncovered care (see example no. 2). Where it is medically predictable that a patient will require a covered level of SNF care within a specific time frame, the fact that an individual enters an SNF immediately upon discharge from the hospital for noncovered care does not negate coverage at a later date, assuming the requirements of the law are met (see example no. 3).
A patient who has had an open reduction of a fracture of the neck of the femur and has a history of diabetes mellitus and angina pectoris is discharged from the hospital on January 30, 1981, and admitted immediately to an SNF. He requires among other services careful skin care, appropriate oral medications, a diabetic diet, a therapeutic exercise program to preserve muscle tone and body condition, and observation to detect signs of deterioration in his condition or complications resulting from his restricted mobility, which necessitates skilled management of his care to ensure his safety and recovery. It is also medically predictable that when he reaches weight bearing, skilled rehabilitative services will be required. After he is in the SNF for 2 days, he becomes unhappy and at his request is released to his home in the care of a full-time private duty nurse. Five weeks later when he reaches weight bearing he is readmitted to the SNF for the needed rehabilitative care. The patient would be eligible for coverage under the program for the care furnished him during both of these stays.
An individual is admitted to an SNF for daily skilled rehabilitative care which as a practical matter can only be provided on an inpatient basis in an SNF. After 3 weeks the therapy is discontinued because the patient's condition has stabilized and daily skilled services are no longer required. Six weeks later, however, as a result of an unexpected change in the patient's condition, daily skilled services are again required. Since the second period of treatment did not constitute care which was predictable at the time of hospital discharge and could not thus be considered as care which was deferred until medically appropriate, it would not represent an exception to the 30-day rule. Therefore, since more than 30 days of noncovered care had elapsed between the last period of covered care and the reinstitution of skilled services, reimbursement could not be made under the extended care benefit for the latter services.
A patient whose right leg was amputated was discharged from the hospital and admitted directly to an SNF on January 30, 1981. Although upon admission to the SNF the patient required help with meeting his activities of daily living, he did not require daily skilled care. Subsequently, however, after the stump had healed, daily skilled rehabilitative services designed to enable him to use a prosthesis were required. Since at the time of the patient's discharge from the hospital it was medically predictable that at a predeterminable time interval covered SNF care would be required, and since such care was initiated when appropriate, the patient would be entitled to extended care benefits for the period during which such care was provided.
d. Effect of delay in initiation of deferred care
As indicated, where the required care commences within the anticipated time frame the transfer requirement would be considered met even though more than 30 days have elapsed. However, situations may occur where complications necessitate delayed initiation of the required care and treatment beyond the usual anticipated time frame (e.g., skilled rehabilitative services which will enable an amputee patient to use a prosthetic device must be deferred due to an infection in the stump). In such situations, the 30-day transfer requirement may still be met even though care is not started within the usual anticipated time frame, if the care is begun as soon as medically possible and the care at that time is still reasonable and necessary for the treatment of a condition for which the patient received inpatient hospital care.
e. Effect on spell of illness
In the infrequent situation where the patient has been discharged from the hospital to his home more than 60 days before he is ready to begin a course of deferred care in an SNF, a new spell of illness begins with the day the beneficiary enters the SNF thereby regenerating another 100 days of extended care benefits. Another qualifying hospital stay would not be required, providing the care furnished is clearly related to the hospital stay in the previous spell of illness and represents care for which the need was predicted at the time of discharge from such hospital stay.
3. Readmission to an SNF
If an individual who is receiving covered posthospital extended care leaves an SNF and is readmitted to the same or any other participating SNF for further covered care within 30 days, the 30 day transfer requirement is considered to be met. Thus, the period of extended care services may be interrupted briefly and then resumed, if necessary, without hospitalization preceding the readmission to an SNF. (See C.2.a. above for situations where a period of more than 30 days between SNF discharge and readmission, or more than 30 days of noncovered care in an SNF, is followed by later covered care.)
4. Transfer rules
Transfer rules for SNF admissions subsequent to October 29, 1972, and prior to December 5, 1980
Under the transfer rules in effect during this time frame an individual must have been admitted to a participating SNF, and have required and received a covered level of care within 14 days after discharge from a qualifying hospital stay, unless one of the exceptions in subsection b., item 1) or 2) below applies.
b. Nonavailability of appropriate bed space in a participating SNF
Intervals of up to 28 days were permitted where transfer to a participating SNF (for this purpose a “participating SNF” includes only those facilities participating under title XVIII) was deferred under the following conditions:
The individual required within the 14-day period after the hospital discharge, and continued to require through admission to the SNF, a covered level of SNF care for a condition for which he received inpatient hospital care, and he met all other extended care requirements and either 2) or 3) below.
There was no bed available in the facilities ordinarily utilized in the geographic area in which the beneficiary resided. (A private room is considered an “available bed” for this purpose.)
The geographic area in which a beneficiary resides should be defined in such a way that a patient would not be taken away from his family and transported over great distances;
There was an available bed in an SNF but it did not constitute appropriate bed space for the patient. In determining whether appropriate bed space was available, consideration should be given only to whether the facility in which a vacant bed was available had the capacity to meet the individual's medical needs, i.e., was capable of providing the required skilled services. Such nonmedical considerations as the individual's or his physician's preference for a particular SNF should not be considered.
c. Medical appropriateness
An elapsed period of more than 14 days was permitted for SNF admissions where the patient's condition made it medically inappropriate to begin an active course of treatment in an SNF within 14 days after hospital discharge, and it was medically predictable at the time of the hospital discharge that he would require covered care within a predeterminable time period. The fact that a patient entered an SNF immediately upon discharge from a hospital, for either covered or noncovered care, does not necessarily negate coverage at a later date, assuming the subsequent covered care was medically predictable.
d. Readmission to an SNF
If an individual who was receiving covered posthospital extended care left an SNF and was readmitted to the same or any other participating SNF for further covered care within 14 days, the 14 day transfer requirement was considered to be met. Thus, the period of extended care services could be interrupted briefly and then resumed, if necessary, without hospitalization preceding the readmission to an SNF. (See c. above for situations where a period of more than 14 days between SNF discharge and readmission, or more than 14 days of noncovered care in an SNF, was followed by later covered care.)