Medicare and Rehab stay

[Anonymous]

My father has severe hip pain along with congestive heart failure, has lost all mobility in the past month. In the hospital now, but guessing they will recommend stay at rehab facility.

My question is are there only certain facilities that accept medicare (he has A, B and F supplement) and we have the choice of upgrading or being out of network or do most places take medicare? Do we get to choose which one he goes to?

Any thoughts or experiences to share?

[Anonymous]

Almost every rehab facility will accept Medicare (the version your dad has; if he had a Medicare Advantage plan you would have to worry about networks, but it looks like he has original Medicare and a Medigap plan so that’s good). Note that they could recommend a skilled nursing facility, inpatient rehab hospital, or home health care. The hospital will likely recommend a place, but you should proactively ask to speak with a hospital discharge planner to find out the places they work with and do your own work on where you want him to go. Good luck.

[Anonymous]

PP here. Another note is that in order for Medicare to pay for care in a SNF or rehab hospital, your dad will need to an inpatient for at least 3 days (3 midnights). You should confirm with the hospital that he has actually been admitted (rather than being held for observation), and that he has been there 3 days before he is to be discharged to a post-acute care setting.

[Anonymous]

To add to what PPs have said, admission and length of stay will depend on ability to tolerate therapy. If he can’t actively participate three hours a day, he’ll qualify for a skilled nursing facility based rehab center. If he is not making regular progress after admission he will be discharged. When he meets the MC threshold for mobility and other activities, he will be discharged regardless of whether he could progress further.

[Anonymous]

Thanks for this information!

One more question - if Medicare pays for shared room only, is it possible to upgrade to private room and pay the difference?

[Anonymous]

Anonymous wrote:Thanks for this information!

One more question - if Medicare pays for shared room only, is it possible to upgrade to private room and pay the difference?

That will depend on the facility. Medicare pays what it pays.

[Anonymous]

Most/all hospitals have some type of care manager/social worker/aftercare planner who will help you navigate this. Get in touch with them now and start looking at your options.

If a patient needs to go to rehab, what often happens at discharge is that the hospital will send them to the first available. If you have a facility you prefer, get on their waiting list now as the hospital won't keep the patient to wait for a specific facility.

[Anonymous]

My Dad was at a place that only had private rooms and Medicare covered it....until they didn't.

[Anonymous]

Anonymous wrote:My Dad was at a place that only had private rooms and Medicare covered it....until they didn't.

OP, this is a good point here and will provide a little more depth: your dad will need to make progress in his therapy in order for his stay to be covered by Medicare. Hospital staff, etc may say, "he has 30 days of rehab therapy covered by Medicare, then Medicare pays for X% after 30 days....," but if he is not making progress in the early weeks, then Medicare will cut him loose and fast.

My dad was in a facility where he was able to remain when he "failed" his therapy within a few weeks, maybe just ten days, and we were lucky that there was a "Medicaid" bed available for him at the home, even if he was private pay for some months while applying. Depending on your dad's finances, you may want to take some of those factors into consideration. The hospital discharge staff may be great and help you consider all the factors or they may be overworked and your dad is simply a number on a to-do list and its' "place him wherever you can."

Regarding private room, I don't know about Medicare, but when our dad entered hospice-in-place, we were not allowed under Medicaid to pay the difference to have a private room.

Good luck to your dad!

[Anonymous]

Anonymous wrote:

Anonymous wrote:My Dad was at a place that only had private rooms and Medicare covered it....until they didn't.

OP, this is a good point here and will provide a little more depth: your dad will need to make progress in his therapy in order for his stay to be covered by Medicare. Hospital staff, etc may say, "he has 30 days of rehab therapy covered by Medicare, then Medicare pays for X% after 30 days....," but if he is not making progress in the early weeks, then Medicare will cut him loose and fast.

My dad was in a facility where he was able to remain when he "failed" his therapy within a few weeks, maybe just ten days, and we were lucky that there was a "Medicaid" bed available for him at the home, even if he was private pay for some months while applying. Depending on your dad's finances, you may want to take some of those factors into consideration. The hospital discharge staff may be great and help you consider all the factors or they may be overworked and your dad is simply a number on a to-do list and its' "place him wherever you can."

Regarding private room, I don't know about Medicare, but when our dad entered hospice-in-place, we were not allowed under Medicaid to pay the difference to have a private room.

Good luck to your dad!

This is completely not true. Patients so not have to make progress to continue rehab under Medicare. You should appeal if anyone tells you otherwise.

In essence, the Jimmo Settlement Agreement clarifies Medicare’s longstanding policy that coverage of skilled nursing and skilled therapy services in the Skilled Nursing Facility (SNF), Home Health (HH), and Outpatient Therapy (OPT) settings does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.

https://medicareadvocacy.org/jimmo-v-sebelius-factsheet-medicare-skilled-nursing-facility-coverage-does-not-require-improvement/

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:My Dad was at a place that only had private rooms and Medicare covered it....until they didn't.

OP, this is a good point here and will provide a little more depth: your dad will need to make progress in his therapy in order for his stay to be covered by Medicare. Hospital staff, etc may say, "he has 30 days of rehab therapy covered by Medicare, then Medicare pays for X% after 30 days....," but if he is not making progress in the early weeks, then Medicare will cut him loose and fast.

My dad was in a facility where he was able to remain when he "failed" his therapy within a few weeks, maybe just ten days, and we were lucky that there was a "Medicaid" bed available for him at the home, even if he was private pay for some months while applying. Depending on your dad's finances, you may want to take some of those factors into consideration. The hospital discharge staff may be great and help you consider all the factors or they may be overworked and your dad is simply a number on a to-do list and its' "place him wherever you can."

Regarding private room, I don't know about Medicare, but when our dad entered hospice-in-place, we were not allowed under Medicaid to pay the difference to have a private room.

Good luck to your dad!

This is completely not true. Patients so not have to make progress to continue rehab under Medicare. You should appeal if anyone tells you otherwise.

In essence, the Jimmo Settlement Agreement clarifies Medicare’s longstanding policy that coverage of skilled nursing and skilled therapy services in the Skilled Nursing Facility (SNF), Home Health (HH), and Outpatient Therapy (OPT) settings does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.

https://medicareadvocacy.org/jimmo-v-sebelius-factsheet-medicare-skilled-nursing-facility-coverage-does-not-require-improvement/

My dad was kicked out of Medicare rehab a year before this settlement.

So, Medicare covers all LTC charges for someone who enters rehab, doesn't regain some or all of their skills (e.g., walking), and is confined to bed? Medicare covers the duration of their stay, including end of life, even if this for 1, 2, or 3 or more years?

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:My Dad was at a place that only had private rooms and Medicare covered it....until they didn't.

OP, this is a good point here and will provide a little more depth: your dad will need to make progress in his therapy in order for his stay to be covered by Medicare. Hospital staff, etc may say, "he has 30 days of rehab therapy covered by Medicare, then Medicare pays for X% after 30 days....," but if he is not making progress in the early weeks, then Medicare will cut him loose and fast.

My dad was in a facility where he was able to remain when he "failed" his therapy within a few weeks, maybe just ten days, and we were lucky that there was a "Medicaid" bed available for him at the home, even if he was private pay for some months while applying. Depending on your dad's finances, you may want to take some of those factors into consideration. The hospital discharge staff may be great and help you consider all the factors or they may be overworked and your dad is simply a number on a to-do list and its' "place him wherever you can."

Regarding private room, I don't know about Medicare, but when our dad entered hospice-in-place, we were not allowed under Medicaid to pay the difference to have a private room.

Good luck to your dad!

This is completely not true. Patients so not have to make progress to continue rehab under Medicare. You should appeal if anyone tells you otherwise.

In essence, the Jimmo Settlement Agreement clarifies Medicare’s longstanding policy that coverage of skilled nursing and skilled therapy services in the Skilled Nursing Facility (SNF), Home Health (HH), and Outpatient Therapy (OPT) settings does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.

https://medicareadvocacy.org/jimmo-v-sebelius-factsheet-medicare-skilled-nursing-facility-coverage-does-not-require-improvement/

My dad was kicked out of Medicare rehab a year before this settlement.

So, Medicare covers all LTC charges for someone who enters rehab, doesn't regain some or all of their skills (e.g., walking), and is confined to bed? Medicare covers the duration of their stay, including end of life, even if this for 1, 2, or 3 or more years?

No...there are still limits that are capped at about 100 days.

[Anonymous]

Many elderly are kicked out because they refuse to participate in the therapy.

[Anonymous]

The Jimmo case is widely ignored and unknown in my experience. You’d think providers would want to keep getting Medicare funding for therapies but instead they stop providing when they stop seeing measurable progress. Try to be persistent.
Also, if your dad happens to have tricare 4 life alongside Medicare, tricare may pay for nursing home care after the Medicare 100 days have run out.

[Anonymous]

Under Jimmo, need for skilled care essentially means that you would deteriorate without it or that it necessary to slow deterioration. That is still a tough hoop to jump through though not as tough as needing to progress.