If Medicare runs out, can it be restarted?

3 answers | Last updated: Jul 28, 2017
A fellow caregiver asked...

My brother-in-law went into the hospital after suffering a stroke. He was then assigned to a skilled nursing facility. He had both Medicare and Tricare. Now both have run out. Here is the question: if he went back into the hospital for two days will Medicare or Tricare pay for his care when he is returned to the facility?

Expert Answers

Medicare payments for care in a skilled nursing facility last for only 100 days within any one "benefit period." Within that 100 days, Medicare pays the full amount for the first 20 days, then requires the patient to pay a daily copayment during the next 80 days. TRICARE pays that copayment. After 100 days, though, Medicare covers no more skilled nursing facility coverage within that same benefit period.

The whole payment cycle for your brother-in-law's skilled nursing facility care could begin again, however, if he enters a new benefit period. In that new benefit period, Medicare would again pay for another 100 days, with TRICARE paying copayments. You've rightly identified part of what's needed for new Medicare skilled nursing facility coverage -- a new hospital stay. But that new hospital stay must be for 3 days (not counting the day of discharge), not 2 days. And there's another requirement that must be met before Medicare considers that your brother-in-law has entered a new benefit period. That is, he must have been OUT of both the hospital and the skilled nursing facility for 60 consecutive days before a new benefit period can begin. Unless he has that 60-day period out of the hospital and skilled nursing facility, a new Medicare benefit period does not begin and there is no further Medicare coverage for his nursing facility stay.

Community Answers

A fellow caregiver answered...

Joseph is exactly right and this just happened to my Dad, who still needed in-house rehab before he could safely return home. His medical costs where are still covered by Medicare/supplemental insurance, just not the facility stay. In our case, Dad has only Social Security income and no assets, so we were able to qualify him for Medicaid to cover the facility stay. Be aware though, that when you do that, the facility gets his income (in this case social security) minus the supplemental insurance premium and A small spending allowance.

Leishasparks answered...

Since he has Tricare as his secondary, you could have, or the skilled nursing facility could have contacted Tricare and requested an authorization for Tricare to become Primary with day 101 . If approved Tricare gives authorizations in 30-day increments to become Primary payer for skilled days 101 and beyond.