Medicare and Rehab stay

[Anonymous]

OP here - this is all great information. Thanks so much for the responses.

My father will likely be transferred to a Rehab Friday or Saturday (thanks to advice here he will have had three midnights so Medicare can cover it)... The hospital is waffling between recommending Rehab or skilled nursing, but we are pushing Rehab as hard as we can.

[Anonymous]

Anonymous wrote: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.

Is skilled care different than what is offered in a LTC facility?

[Anonymous]

Anonymous wrote:

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.

Right. So OP may want to weigh where her dad is transferred to based on his financial status. If he has LTC insurance, is wealthy, etc, then he may have a lot of options. But if his resources are limited and applying for Medicaid is a possibility, then it is MUCH better for him to enter rehab in a facility where he could transition to if he is not able to return home, etc.

[Anonymous]

I just went through this really recently. Here's what I have learned:

- The 3 day rule has been relaxed because of Covid and hospitals wanting people out sooner but you may want to double check that
- I *think* after a hospital discharge you have 30 days to enter rehab. It does not need to be directly from the hospital AFAIK. Loved one actually did not go directly to rehab following hospital.
- Medicare would pay for 20 days of rehab at 100% for my loved one. Not sure how you get 100 days -- maybe they are paying less than 100%?
- Tricare for Life if you have it will pay for days 21+ (not sure how long it will cover, I think up to day 60 at 100%)
- Do your research on rehab places and pick one that works for you and has good reviews. You then ask the social worker to make the referral. Don't let them decide. You want one with good reviews that is convenient to you. There are really bad places. You can also delay his discharge a bit for a bed to open where you need it if you're at a nice hospital.
- The best places in Northern Virginia are Goodwin House and Arleigh Burke from what I have heard (Arleigh Burke has 10 private Medicare covered beds, not sure about Goodwin House)
- Call to see if the rehab place is only private beds. If they only do private beds then Medicare will cover that since there is not another option. They also will cover a private bed if it is medically necessary.

You can say that he has weakened in the hospital and needs to get rehab to recover from a hospital stay. But in my experience if he isn't making progress they will try to push him along someplace else like Assisted Living and that would be private pay unless he is on Medicaid. It isn't necessarily just PT, it could be progress with OT, too.

If you know of a Medicare paid skilled nursing place I would love to know which one and how long you can stay under Medicare.

[Anonymous]

Anonymous wrote: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.

I don't know about for skilled nursing facilities and rehab places, but for home care I know what the problem is.

Providers are evaluated based on whether their patients make improvement. So sure, Medicare in theory will continue to pay, (or it is supposed to) but the providers get "dinged" because the patient doesn't make any progress towards goals. So the providers don't want the patients because it makes their stats go down and then they will get in trouble with Medicare.

[Anonymous]

Anonymous wrote:

Anonymous wrote: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.

Is skilled care different than what is offered in a LTC facility?

I think so. Skilled care means they need P/T, O/T and nursing care for sure.

https://medicareadvocacy.org/medicare-coverage-of-skilled-care-nine-services-that-are-skilled-by-definition

I think LTC is more custodial? Daily needs like bathing, dressing?

[Anonymous]

You learn quickly that rehab is just the polite name for a nursing home.

[Anonymous]

Anonymous wrote:I just went through this really recently. Here's what I have learned:

- The 3 day rule has been relaxed because of Covid and hospitals wanting people out sooner but you may want to double check that
- I *think* after a hospital discharge you have 30 days to enter rehab. It does not need to be directly from the hospital AFAIK. Loved one actually did not go directly to rehab following hospital.
- Medicare would pay for 20 days of rehab at 100% for my loved one. Not sure how you get 100 days -- maybe they are paying less than 100%?
- Tricare for Life if you have it will pay for days 21+ (not sure how long it will cover, I think up to day 60 at 100%)
- Do your research on rehab places and pick one that works for you and has good reviews. You then ask the social worker to make the referral. Don't let them decide. You want one with good reviews that is convenient to you. There are really bad places. You can also delay his discharge a bit for a bed to open where you need it if you're at a nice hospital.
- The best places in Northern Virginia are Goodwin House and Arleigh Burke from what I have heard (Arleigh Burke has 10 private Medicare covered beds, not sure about Goodwin House)
- Call to see if the rehab place is only private beds. If they only do private beds then Medicare will cover that since there is not another option. They also will cover a private bed if it is medically necessary.

You can say that he has weakened in the hospital and needs to get rehab to recover from a hospital stay. But in my experience if he isn't making progress they will try to push him along someplace else like Assisted Living and that would be private pay unless he is on Medicaid. It isn't necessarily just PT, it could be progress with OT, too.

If you know of a Medicare paid skilled nursing place I would love to know which one and how long you can stay under Medicare.

yes, less than 100% but can't remember the percentage.

OP, PP is right on about calling around. Didn't have a lot of options with our dad as our mom wanted him to be as close as possible. We were able to be more choosy with our mom - she got into a great non-profit memory care unit.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote: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.

Is skilled care different than what is offered in a LTC facility?

I think so. Skilled care means they need P/T, O/T and nursing care for sure.

https://medicareadvocacy.org/medicare-coverage-of-skilled-care-nine-services-that-are-skilled-by-definition

I think LTC is more custodial? Daily needs like bathing, dressing?

Got it - thanks. The Jimmo (sp?) settlement seems fairly narrow as I'm guessing many people who do not make progress probably need more custodial than skilled care. Wouldn't want OP to base decisions based on one poster's interpretation of the decision.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote: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.

Is skilled care different than what is offered in a LTC facility?

I think so. Skilled care means they need P/T, O/T and nursing care for sure.

https://medicareadvocacy.org/medicare-coverage-of-skilled-care-nine-services-that-are-skilled-by-definition

I think LTC is more custodial? Daily needs like bathing, dressing?

Got it - thanks. The Jimmo (sp?) settlement seems fairly narrow as I'm guessing many people who do not make progress probably need more custodial than skilled care. Wouldn't want OP to base decisions based on one poster's interpretation of the decision.

I think Jimmo covers people with neurological problems like ALS, MS etc. well, but not able bodied people with, say, dementia. They need custodial (memory) care, but they don't actually need P/T, O/T etc.

[Anonymous]

Anonymous wrote: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.

Are you saying that Medicare (original) is better to have than a Medicare Advantage plan?

[Anonymous]

What Does Jimmo Mean for My Patients?
The Jimmo Settlement means that Medicare beneficiaries should not be denied maintenance nursing or therapy when skilled personnel must provide or supervise the care for it to be safe and effective. Medicare-covered skilled services include care that improves, maintains, or slows the decline of a patient’s condition. Thus, Medicare coverage should not be denied solely because an individual has an underlying condition that will not get better (such as MS, ALS, Parkinson’s disease, or paralysis).

https://medicareadvocacy.org/jimmoproviderbrief/#:~:text=The%20Jimmo%20Settlement%20applies%20to,has%20a%20Medicare%20Advantage%20plan.

[Anonymous]

Question: Are there time limits for the coverage of skilled nursing and skilled therapy services?

Answer: The Jimmo Settlement does not include any time limits for Medicare coverage. The rules for the health care settings covered by Jimmo vary.

For home health, as long as the skilled nursing or skilled therapy services are necessary to maintain the patient’s functioning or to prevent or slow the patient’s decline or deterioration, there are no time limits to home health care. Medicare beneficiaries are entitled to ongoing coverage, which may last years, as long as all coverage criteria are met.

There are similarly no time limits for outpatient therapy. Medicare has therapy “caps” for payment for covered services, but there is an exceptions process that authorizes coverage for medically necessary therapy services that exceed the caps. The exceptions process is applicable to maintenance therapy as well as to therapy that is provided with an expectation of improvement.

Coverage for a stay in a skilled nursing facility under Medicare Part A is limited to 100 days in a benefit period for residents needing therapy services five days a week. (Under Part A, Medicare covers room and board, nursing services, therapy services, and medications.) However, if a skilled nursing facility resident has used all 100 days in a benefit period or if the resident needs fewer than five days a week of skilled therapy services, these services can be covered by Medicare Part B. The coverage standards for therapy under Parts A and B are the same. However, Part B payments can continue indefinitely, if coverage standards are met.

https://medicareadvocacy.org/jimmo-v-sebelius-the-improvement-standard-case-faqs

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote: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.

Is skilled care different than what is offered in a LTC facility?

I think so. Skilled care means they need P/T, O/T and nursing care for sure.

https://medicareadvocacy.org/medicare-coverage-of-skilled-care-nine-services-that-are-skilled-by-definition

I think LTC is more custodial? Daily needs like bathing, dressing?

Got it - thanks. The Jimmo (sp?) settlement seems fairly narrow as I'm guessing many people who do not make progress probably need more custodial than skilled care. Wouldn't want OP to base decisions based on one poster's interpretation of the decision.

I think Jimmo covers people with neurological problems like ALS, MS etc. well, but not able bodied people with, say, dementia. They need custodial (memory) care, but they don't actually need P/T, O/T etc.

TY for sharing this. I can see how there would be some folks who would read about the case and think it would cover a family member with dementia, etc when that would not be the case.

[Anonymous]

In my experience Medicare will cover skilled nursing not unskilled nursing.

Skilled nursing is things like catheters, diabetic care (the dialysis you can do at home), etc. Medicare will cover a couple hours a week at home through one of the zillion providers out there. Also at home OT/PT -- I think twice a week.

Unskilled nursing is not covered by Medicare. Unskilled is help with activities of daily living like bathing, eating, dressing, etc.

Rehab places will provide both skilled/unskilled nursing covered of course like at the hospital.

But if you still need unskilled after the stay AFAIK it is all private pay via home health aides or private pay assisted living places like Sunrise. It sucks but you might want to look at those assisted living places/finances.