I was on the senior care forums these past few days and one of the threads was talking about how many days are covered by Medicare in a Nursing Home or Rehab after a hospital stay. The answers were all over the map and quite confusing I must confess, so I thought I would do a post about it to clear things up. I have always told my readers I am no expert, but when it comes to this subject I know it all to well. You see mom has been in and out of rehab 3 times in the past 2 years so we know the rules by heart.
According to Medicare rules a person must have a qualifying hospital stay of at least 3 days
( 24 hours) and be in need of further skilled nursing or rehab care in order for them to pay for the stay. The doctor and the physical therapy department at the hospital must agree that the patient would benefit from continued care or therapy at a nursing home or rehab facility.
It is important to note at this point that the patient needs to be an inpatient at the hospital for 3 days, and time spent in observation or the ER does not count. They have to be admitted to the hospital. This is very important!
Insurance companies and Medicare are putting increased pressure on doctors so that they do not admit patients. They have narrowed the guidelines for admittance and now many patients are ending up in observation for 1, 2 or 3 nights and then they do not qualify to go to rehab under Medicare.
If a person has a qualifying stay of 3 days then Medicare will pay for nursing home or rehab as follows:
Day 1-20 Covered 100%
Day 21-100 partial coverage with a 161.00 a day co-pay
Day 101 and beyond no coverage
Many Medicare supplement policies like the one my mother has will cover the copay on days 21-100 so there is no out of pocket for the patient. However this is something you should look into ahead of time so you know your coverage should you or a loved one be in this situation.
During the time in rehab the patient must continue to show that the services provided are helping them to improve. So if at anytime during their stay the team feels they have done all they can for the patient the team is obligated to discharge them, even if they have days left.
Now there is something to be said about having days left over. If the patient leaves rehab or nursing care and they need to be readmitted to the facility within 30 days and have days remaining they will have coverage through Medicare. If they use up all their days then they would have to wait 60 days and have another qualifying hospital stay of 3 days before Medicare would pay for skilled nursing care or rehab again. This would start their 100 day benefit period over again.
I am providing a link here that goes to the Medicare.gov site for skilled nursing care. It has more information for you.
The last time mom went into the hospital the doctors would not admit her but put her in observation for 4 nights. This really made us angry because observation did everything the same as if she had been admitted. We thought she would not be able to go to rehab which she needed very much as she was having trouble walking and was very weak. However the discharge planner was a gem. She arranged for mom to be transfered to a rehab hospital
( didn't know there was such a thing) where she was able to stay for several nights thus giving her the qualifying stay she needed to be transferred to the rehab facility near our home. She continued her rehab for another month at that facility. So make sure to connect with the discharge planners well in advance of discharge. They are so good at finding ways to make things work and we would have been lost with out her.
I do hope this information helps you understand the process a bit better. If you have any questions or comments please feel free to contact me or leave a comment at the bottom. I always love to hear from you.
Until Next Time