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Medicare coverage for inpatient rehab varies

Q:  Our church has a weekly social gathering for older adults. We provide light refreshments in addition to information gathering about topics related to aging. Several members have asked questions about who pays if they have to go to rehab in a nursing home. Does Medicare covers those costs?

A:  This is a complex question, and my answer covers the basics of what Medicare pays for concerning rehabilitation services. For Medicare to pay for rehabilitation services, the patient must have been in the hospital for a minimum of three days which is covered under Medicare Part A benefits. If it is determined by the medical team (doctor and therapists) that additional daily care or services are needed, and the health condition of the patient means those services can only be received in a Skilled Nursing Facility or SNF (another name for nursing home) on an inpatient basis, Medicare will cover the costs under Part B. Day 1-20 would be at no cost to the patient or beneficiary, days 21-100 would have a co-payment unless there is additional insurance to offset the cost.

The typical health issues that warrant these rehabilitation services are if a patient requires nursing oversight, and intensive physical, occupational or speech therapies. In the first days of admission, medical staff will devise a care plan and set goals for the individual. During the stay Medicare requires assessments to be made to determine progress in the patient’s recovery and rehabilitation potential. There is not a set number of days for rehabilitation per specific admitting diagnosis. Every patient is assessed for his or her personal rehab potential.

The term “plateau” may be used at some point, meaning the patient has experienced a period of little or no change and no further improvement is expected. At that point, medical staff may determine continued inpatient care is no longer meaningful. So for example, you could have two patients admitted to the same rehabilitation facility with the same diagnosis. One person continues to show improvement in his or her condition, while the other patient has hit a “plateau” and is no longer progressing. Those differences impact the number of days Medicare will approve in a SNF. No one is guaranteed 100 days of coverage. It is dependent on the medical plan and the progress made.

Extensive information is available on-line at www.medicare.gov regarding Medicare’s coverage of the rehabilitation benefit. We would also encourage consumers to call the SHINE program for additional questions. To find a SHINE counselor near you please contact our Age Information Department.

 

Are you struggling caring for an older adult or having difficulty locating resources? Our staff is available for a no-cost consultation, set up at your convenience, to help guide you through your caregiving experience. For more details or to schedule an appointment, please call 800-892-0890.

Do you have a question? We encourage inquiries and comments from our readers. Please direct your correspondence to ageinfo@esmv.org or Elder Services of the Merrimack Valley, Inc., Age Information Department, 280 Merrimack Street, Suite 400, Lawrence, MA 01843. Joan Hatem-Roy is the Chief Executive Officer of Elder Services.