Q. I hear that Medicare has announced that, due to the Corona Virus Pandemic, it will now be more generous in covering nursing home stays by relaxing some of its long-standing coverage requirements. Do you know anything about this?

A. Yes. A bit of background may be helpful. Medicare has traditionally imposed three conditions as prerequisites to covering nursing home care, more properly known as Skilled Nursing Facility (“SNF”) coverage:

(1) The 3 Midnights Rule:  The patient must have spent at least three (3) nights in the hospital as an admitted patient before being discharged to a nursing home (aka a Skilled Nursing Facility, or “SNF”);

(2)  100 Day Cap For Single Spell of Illness:  The duration of coverage would not, in any event, last longer than 100 days for a “single spell of illness”. That 100 day limit could only be extended in the rare case where the patient established a new benefit period by “breaking” that single spell of illness. A break occurs where he or she was discharged from the SNF to either return home, or to a custodial care setting, for at least 60 continuous days. In the rare case where that break occurred, only then could the individual re-qualify for another SNF benefit period of up to 100 days. However, see “New Development“, below ; and

(3) Must Need Skilled Care:  The coverage, in any event, would be for only for so long as the SNF patient needed skilled therapies (e.g. Occupational Therapy, Physical Therapy, Speech Therapy, wound care); when it appeared that the patient needed only custodial care, Medicare coverage would end even if before the 100 day limit.

New Development as of 03/13/2020:  Because of the Corona Virus Pandemic, the Administrator of the Center for Medicare & Medicaid Services, Seema Verma, recently announced major changes in how Medicare covers SNF level care:  On behalf of Medicare, she has now eliminated or substantially relaxed the “3 Midnights Rule” and the “Single Spell of Illness” rule. Thus, to qualify for SNF level Medicare coverage now, an individual need not first spend three nights in the hospital. Likewise, he or she can now receive a second benefit period of up to 100 additional days without first needing to return home for 60 days. Further, the federal CMS Agency has just released clarifying Questions and Answers. In particular, the extension does NOT depend upon having a COVID-19 related illness. See the link in the References section, below.

However, the requirement that the individual must still show the continued need for skilled care, as opposed to custodial care, remains in effect. Thus, if the individual were granted a second 100 benefit period of coverage, but was unable to fully participate in physical or occupational therapies during that new benefit period, then coverage would still end before the full 100 day coverage extension. Thereafter, if his doctor still felt that he still needed care in the nursing home, the individual would then have to either pay from his or her own funds or apply for Medi-Cal coverage.

Remember:  Medi-Cal – unlike Medicare—will pay even for custodial level care for those who financially qualify, and for so long as needed, even if it be for the remainder of an individual’s lifetime.

References:  Letter from Seema Verma, Administrator, Center for Medicare & Medicaid Services, 03/13/2020; Article by American Health Care Association; Questions & Answers about the Medicare Rule. See, the Q&A on page 98: The Q and A reads as follows:

“Y. Skilled Nursing Facility Services 1. Question: Does the section 1812(f) waiver for the 3-day qualifying hospital stay apply only to those beneficiaries who are actually diagnosed with COVID-19, or does the waiver apply to all SNF-level beneficiaries under Medicare Part A? Answer: The qualifying hospital stay waiver applies to all SNF-level beneficiaries under Medicare Part A, regardless of whether the care the beneficiary requires has a direct relationship to COVID-19. See: https://www.cms.gov/About-CMS/AgencyInformation/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page