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 their 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.

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 they will require and the time frame in which it will be required is dependent on the developing nature of their condition, their 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 they will require additional care at some time in the future. However, at the time of their 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 they 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 their 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.

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).

Example 1:

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. They require 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 their condition or complications resulting from their restricted mobility, which necessitates skilled management of their care to ensure their safety and recovery. It is also medically predictable that when they reach weight bearing, skilled rehabilitative services will be required. After they are in the SNF for 2 days, they become unhappy and at their request is released to their home in the care of a full-time private duty nurse. Five weeks later when they reach weight bearing they are readmitted to the SNF for the needed rehabilitative care. The patient would be eligible for coverage under the program for the care furnished them during both of these stays.

Example 2:

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.

Example 3:

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 their activities of daily living, they did not require daily skilled care. Subsequently, however, after the stump had healed, daily skilled rehabilitative services designed to enable them 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.

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.

In the infrequent situation where the patient has been discharged from the hospital to their home more than 60 days before they are 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.

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.

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:

1. 1. 

   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 they received inpatient hospital care, and they met all other extended care requirements and either 2) or 3) below.

2. 2. 

   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 their family and transported over great distances;

3. 3. 

   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 their physician's preference for a particular SNF should not be considered.

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 they 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.

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.)