Medicare Regulations on Staying in a Extended Care Facility

Medicare's extended-care benefits cover short-term patient care following a hospitalization. Medicare requires physician certification that the stay in a skilled nursing facility is necessary for daily services or care. A patient must remain in the hospital for 3 consecutive days with a related illness or injury. The hospitalization qualification begins when the patient is admitted. Time spent in an emergency room, observation, clinic or outpatient care does not count toward the qualifying stay.

Admittance Deadline

• Medicare requires admittance into an extended-stay facility within 30 days of a hospital discharge. The chosen facility and its beds must be Medicare-certified.

  According to the Center for Medicare & Medicaid Services (CMS), Medicare makes exceptions when it's "inappropriate from a medical standpoint to begin such treatment" after the patient's discharge.

  The doctor is required to predict the time frame for admittance. For instance, typically after a hip fracture, weight bearing is intolerable. After 4 to 6 weeks, the patient is ready for skilled therapy care.

  If the doctor is unable to predict the admittance time frame, the exception is denied. One example is a cancer patient. A doctor is unable to predict when--or if--life support or another skilled care service is needed.

Covered Admittance

• The 3-day admittance was medically necessary.

  A direct connection exists between the hospitalization and the requested care.

  The patient requires daily skilled nursing or rehabilitation services.

  A second professional or technician is required to supervise the necessary services.

  Inpatient services are the most economical and efficient method of providing treatment.

  Services are necessary, reasonable, consistent with the severity and nature of the patient's injury or illness, his individual needs and accepted standards.

  Duration and quantity of services are necessary and reasonable.

  Failure to meet any of these stipulations leads to denial of payment.

  If a patient is rehospitalized and directly returns to a skilled nursing facility to continue her care, Medicare presumes she still meets the qualifying criteria.

Alternative Care

• After 5 days, a Medicare intermediary considers the practicality of using a more economical alternative.

  The first consideration is the patient's current condition. If using an alternative would adversely affect the patient, it's impractical.

  Another consideration is the "availability of a capable and willing family member" to provide care for the patient. If a patient does not have sufficient assistance in his home to safely reside there, outpatient care is an ineffective option.

  An intermediary also considers the patient's physical hardship of daily transportation.