Thursday, September 02, 2010
What is a Medicare stay?
A majority of seniors will spend at least some time in a skilled nursing facility during their lifetime, but most do it in the context of a rehab stay after some event, such as a stroke, fall, or general weakness after illness. These stays are commonly referred to as a Medicare rehab stay. This article will discuss the qualifications for a Medicare rehab stay, the costs associated with those stays, and what happens when the stay ends.
Qualifications
In order for someone to be eligible for a rehab stay, there are several requirements. First, the individual must be eligible and enrolled in Medicare Part A benefits. For someone who has a Medicare Advantage plan, they will also be eligible for rehab stays, but the basic rules and costs will vary from plan to plan. As discussed in previous articles, for Medicare Advantage enrollees, it is very important that they be familiar with all the plan features, because there is a wide difference between plans. Second, the individual must have been admitted to the hospital for 3 consecutive days. Just because an individual was at the hospital doesn’t necessarily mean that the person was admitted, and many times when an individual first goes to the hospital they are under “observation,” which does not count towards the three day requirement. Next, as you leave the hospital, the doctor must agree that you either need some type of therapy (speech, physical, or occupational) or have some other skilled need (such as intravenous injections or certain types of wound care).
Costs
If the person only has “regular” Medicare coverage (meaning parts A & B), then the first 20 days in a skilled nursing facility will be covered 100% by Medicare. This includes the room and board at the skilled facility, the medications, and the therapy. It may not include costs of beauty shop, cable, phone, or other extra costs that are unrelated to care. For days 21-100, the individual will have a copay of $137.50 per day (in 2010, this number changes each year). For most people who have a Medicare supplement plan, the supplement usually covers all of the copay during days 21-100. Some of the less inclusive (and cheaper) supplemental plans don’t cover 100% of the costs. If you have a 60 day rehab stay, that could mean the difference in a $5500 bill, and no bill. But remember, these Medicare supplement plans also had a monthly premium that you pay whether or not you are sick.
How does a rehab stay end?
A rehab stay will last until the earlier of two events. First, 100 days of skilled care during any spell of illness. Second, when there becomes no ongoing skilled care need. Just like there was a requirement of skilled care (such as the need for therapy or other qualifying care) to begin the rehab stay, this requirement must stay present at all times or else Medicare stops paying. It is actually fairly uncommon for a rehab stay to last the entire 100 days, as usually the skilled care need stops before day 100.
What happens next?
Just because Medicare stopped paying, that doesn’t mean the individual is ready to return home. While virtually everyone on a rehab stay hopes to return home, the reality is that a large portion of people will not sufficiently recover to be able to return to living independently in their homes. Sometimes, moving to assisted living, or bringing caregivers into the home can work. Other times, the individual is still impaired enough that they require the 24 hour supervision and assistance that a skilled nursing facility offers, and there isn’t an expectation that the person will recover enough to return home. The individual is more than welcome to stay at the facility, but they will be a private pay resident unless they qualify for Medicaid (MoHealthnet) benefits. Most of the facilities in this area have a private pay rate of between $160 and $200 per day.
For more information about Medicare rehab stays, Medicare produces a nice summary. It is available at http://www.medicare.gov/Publications/Pubs/pdf/10153.pdf.