I’ve covered the topic of short term Medicare admissions quite extensively. It is the most important variable to consider for the admission of anyone over 65 to a skilled nursing or post-acute rehab facility.
So here is my tutorial for the uninitiated (or for the initiated, consider it a refresher!)
Q: Mom was recently admitted to the hospital with a hip fracture. She has been there for 5 nights and the social workers tell me they are ready to discharge her. They are recommending that she first go for in-patient rehabilitation in a post-acute care center before she returns to home. They are telling me that Medicare will pay for her stay. I am so confused about which facility is best for her and what Medicare will pay. Can you help me understand this?
A: The original Medicare plan allows for a beneficiary to receive extended rehabilitation services in an approved facility once the physician documents the need for services. The physician must indicate there is every reason to believe the individual has the capacity to regain additional functional skills or strength. In the Medicare lexicon, they term this “prior level of functioning.” The stay is for rehabilitative purposes and not for long-term care.
Medicare covers the cost for the first 20 days of each benefit period in full at 100%, then the patient is responsible for a 20% co-payment of $152 (2014 rate) for days 21-100. In many instances, if a patient has a secondary or supplemental insurance policy to Medicare (AARP and BCBS are two examples), they will pick up the co-pay for days 21-100.
However, it is important to note (and I am careful to mention this to families all the time) that Medicare will not write a blank check for 100 days to use in a skilled nursing and rehab facility. Rather, they make the reimbursement subject to the goals and objectives of achieving prior level of functioning.
Therefore, it is my experience that (inevitably) patients will seldom go the distance and use all 100 days on one in-patient admission/stay. This is because usually one of two things occur:
1. Patient will sometimes demonstrate the ability to achieve prior level of functioning relatively quickly after which they will plateau and will be cut by Medicare. At that point, the facility can argue all they want for extra time, but Medicare will not pay because the goals have already been met and Medicare doesn’t pay the facility to get the person to run the marathon!
2. Patient demonstrates an inability to achieve prior level of functioning. Basically, their new clinical reality is such, that they will never get back to where they were prior to their hospitalization. Therefore, after 3 days of futile attempts at delivering the requisite therapy, Medicare will cut the reimbursement because there isn’t any (sufficient) progress.
The bottom line is, patients are continuously evaluated to monitor their progress and determine if they have the potential for further progress in order to achieve the goals set forth for their stay. Once it is determined a person has hit a plateau and it is unlikely they will continue to improve the Medicare benefit terminates. Families are often misled to believe everyone is automatically entitled to 100 days of rehabilitation services, it is the exception rather than the norm.
Various options are available regarding the facility in which the rehabilitation services are provided. There are acute care rehabilitation hospitals and long-term care skilled nursing homes, which have a rehabilitation component. The criteria for selection frequently depends on the level of care required and the individual’s potential for reaching a higher functional level. Typically a representative from the facility will do an admissions screening to determine if an individual is appropriate for the level of services they provide. Families should always be involved in the hospital discharge process and will sometimes have the ability to choose which referral they prefer. There will be times when it is determined a patient does not meet the criteria for admission and choices are further limited.
It is always preferable for any patient when family members actively participate in the oversight of care and future plans. The vital role of having someone to advocate for an ill or injured person can sometimes make a difference in the final outcome of patient care. You are to be applauded for your involvement in your mother’s healthcare.
Now go take on the day!