In order to receive therapy in a long-term care facility and have it covered by Medicare the individual must be in the hospital for three days within the previous 30 days. Sometimes hospitals will keep an individual for a limited period of time but list their stay as observation, not inpatient. When this happens the individual will NOT qualify for Medicare!
Traditional Medicare will pay up to 100 days. The coverage will be paid at 100% for the first 20 days and 80% from day 21-100. If the individual has a supplemental insurance they will most likely cover the 20% not covered by Medicare. Understand an individual is not guaranteed 100 days of coverage. Medicare pays until the individual reaches their maximum potential for rehab. Once this is reached Medicare will stop paying. This could be at 10 days or go to the 100 day maximum.
Lifetime reserve days are additional days that Medicare will pay for when an individual is in a hospital for more than 90 days. Individuals are limited to a total of 60 reserve days over the course of their life.
Medicare Advantage Plans have different requirements as far as length of hospitalization and times when co-pays become effective. These plans still offer full or partial coverage for a maximum of 100 days. You need to check your individual policy to see what your benefits are.
Therapies in long-term care include physical therapy, occupational therapy and speech therapy. Speech therapy can be included with physical or occupational therapy but cannot stand alone.
Costs for Medicare Coverage
Medicare Part A premium: Most individuals do not pay a monthly premium for Part A. If you have to buy Part A, it will cost $426 each month in 2014, and $407 in 2015 (this is a reduction).
Medicare Part B premium: The cost for both 2014 & 2015 is $104.90 each month. Part B deductible for 2014 & 2015 is $147 per year.
Part A Hospital deductible: $1216 deductible for each benefit period in 2014, in 2015 the cost goes up to $1260.
Hospital coinsurance for each benefit period for days 1-60 is $0 for both 2014 & 2015. Days 61-90, $304 in 2014 and $315 in 2015. Days 91 and beyond: $608 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime), in 2015 the cost goes up to $630.
When an individual’s Medicare days are about to end the facility is required to send a Notice of Medicare Provider Non-Service to the individual and their legal representative. If the individual does not agree with the decision to terminate Medicare services they can request Demand Billing. Demand Billing will trigger a review of the individual’s case to see if they qualify for more coverage. During the time of the review the individual cannot be charged for Medicare Part A services.