Deferred Covered Treatment in SNF: Understanding Medicare Coverage
20.2.2.3 - 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 may 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 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 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 a 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"
20.2.2.4 - 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."
The Medicare policy allows for deferred covered treatment under specific conditions, enabling patients to access SNF care even if there is a break in their coverage or a delay in starting their treatment. Here are key points regarding deferred covered treatment and its implications:
- Deferred Covered Treatment Eligibility:
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- Patients may be eligible for deferred SNF care if it's medically predictable at the time of hospital discharge that they will require SNF care within a determinable timeframe.
- This eligibility applies even if there's a non-covered interval of more than 30 days between hospital discharge and the commencement of SNF care, provided all other Medicare requirements are met.
- Immediate vs. Future SNF Care:
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- If a patient needs SNF care within 30 days of hospital discharge and it's medically predictable they will need further SNF care in the future, their initial need for care does not negate their eligibility for future coverage.
- This rule is specifically for cases where deferred care is necessary and was predictable at the time of hospital discharge.
- Examples Illustrating Policy Application:
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- Example 1: A patient discharged from the hospital and admitted to an SNF immediately, requiring skilled care later, is eligible for coverage for both stays.
- Example 2: If a patient's second need for SNF care was not predictable at the time of hospital discharge, and more than 30 days of non-covered care have elapsed, they would not be eligible for extended care benefits for the latter services.
- Example 3: A patient admitted to an SNF after hospital discharge who later requires skilled rehabilitative services (which was predictable at discharge) is entitled to extended care benefits.
- Delayed Initiation of Required Care:
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- If complications delay the start of required care beyond the anticipated timeframe, the 30-day transfer requirement can still be met if care begins as soon as medically possible and is necessary for the treatment of a condition related to the hospital stay.
These provisions ensure flexibility in accessing SNF care, recognizing that some patients' medical needs may necessitate deferred treatment that cannot be predicted with precision at the time of hospital discharge
