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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.