Medicare and Rehab stay

[Anonymous]

Anonymous wrote: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.

A 3- day hospital stay is not required for a Medicare- covered stay in a rehab hospital. It is required for a SNF.

[Anonymous]

Anonymous wrote:

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.

Medicare will cover up to 100 days in a skilled nursing facility (different rules apply for a rehab hospital), as long as the patient has had a recent 3-day hospital stay and a physician certifies that the patient needs daily skilled nursing care or rehab therapies. There is no patient copay for days 1-20. Beginning on day 21, the patient is required to pay a copay of up to $200.

There is no requirement that the patient be "making progress," but the facility has to be able to certify that the patient needs skilled care. That's the reason why a Medicare patient might be discharged early from a SNF. (The other reason is that the patient is in a Medicare Advantage plan, and the plan decides it won't pay anymore.) There is zero chance that a SNF voluntarily decides to cut off a traditional Medicare patient-- traditional Medicare pays more for SNF care than many private insurers do and much more than Medicaid.

[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?

Yes, correct.

[Anonymous]

Op here - from what I understand, it makes sense to really push for Rehab over skilled nursing. My parents have some means, but are not bazillionaires, so I'm wondering if anyone has experience with creating a private pay team around the medicare approved home health (2-3 visits a week from nurse and 2x pt week). Ideally we would hire an unskilled nurse to do bathing, and other hygiene stuff as well as supplemental pt. Am I right in believing this would be better than skilled nursing facility? I think our goal of increasing mobility to where he can get himself to and from the bathroom prior to a hip replacement surgery is achievable if we can get him the right, not super depressing support.

Any ideas or BTDT?

[Anonymous]

All short-term rehabs take Medicare.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

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.

Medicare will cover up to 100 days in a skilled nursing facility (different rules apply for a rehab hospital), as long as the patient has had a recent 3-day hospital stay and a physician certifies that the patient needs daily skilled nursing care or rehab therapies. There is no patient copay for days 1-20. Beginning on day 21, the patient is required to pay a copay of up to $200.

There is no requirement that the patient be "making progress," but the facility has to be able to certify that the patient needs skilled care. That's the reason why a Medicare patient might be discharged early from a SNF. (The other reason is that the patient is in a Medicare Advantage plan, and the plan decides it won't pay anymore.) There is zero chance that a SNF voluntarily decides to cut off a traditional Medicare patient-- traditional Medicare pays more for SNF care than many private insurers do and much more than Medicaid.

If one is not in the business, then I think it is not so easy to parse what constitutes "skilled" care. Of course, all of us think our elders deserve skilled care, but it may not be so readily obvious what the difference is between skilled and custodial. Knowing that difference and where one's elder may fall along the arc of it may greatly reduce chaos and confusion for the children and the patient if rehab is not successful.

[Anonymous]

Anonymous wrote:Op here - from what I understand, it makes sense to really push for Rehab over skilled nursing. My parents have some means, but are not bazillionaires, so I'm wondering if anyone has experience with creating a private pay team around the medicare approved home health (2-3 visits a week from nurse and 2x pt week). Ideally we would hire an unskilled nurse to do bathing, and other hygiene stuff as well as supplemental pt. Am I right in believing this would be better than skilled nursing facility? I think our goal of increasing mobility to where he can get himself to and from the bathroom prior to a hip replacement surgery is achievable if we can get him the right, not super depressing support.

Any ideas or BTDT?

I’ve worked in both rehab and SNFs. Not sure that as a blanket statement rehab is better. Depends on the needs, patient tolerance for therapy and facility. What I will say though is that your plan sounds extremely difficult and I would doubt it will be as successful. These facilities structure their entire programs around helping their residents progress. There are hours of therapeutic activity and lots of equipment used every day.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Op here - from what I understand, it makes sense to really push for Rehab over skilled nursing. My parents have some means, but are not bazillionaires, so I'm wondering if anyone has experience with creating a private pay team around the medicare approved home health (2-3 visits a week from nurse and 2x pt week). Ideally we would hire an unskilled nurse to do bathing, and other hygiene stuff as well as supplemental pt. Am I right in believing this would be better than skilled nursing facility? I think our goal of increasing mobility to where he can get himself to and from the bathroom prior to a hip replacement surgery is achievable if we can get him the right, not super depressing support.

Any ideas or BTDT?

I’ve worked in both rehab and SNFs. Not sure that as a blanket statement rehab is better. Depends on the needs, patient tolerance for therapy and facility. What I will say though is that your plan sounds extremely difficult and I would doubt it will be as successful. These facilities structure their entire programs around helping their residents progress. There are hours of therapeutic activity and lots of equipment used every day.

Thanks so much for this perspective - it sounds like I just need to find the highest quality facility that I can.

[Anonymous]

Pretty quickly into rehab the care team sets goals -- PT/OT/speech. The patient does not need to be making progress, but they do need to be responsive in order to stay. There are definitely patients with dementia in rehab who are responsive so able to participate in the therapies but obviously can't make progress in the traditional sense. It's a bit of a nuance -- maintaining vs. responding, I guess.

If he does go to rehab ask the visiting doctors for advice (you might also see a geripsych). They often visit all the rehabs, assisted living, skilled nursing, etc. in the area. It can be hard to catch them but they are a good source of info on the best places because they see them all first hand.

With arranging private duty/home care nursing (unskilled) around the skilled nursing keep in mind that skilled nursing can often run late so you probably would want them to be concurrent. Unskilled nursing is also not a cheap option unless your father will live with you and you can do the overnight shift. It's usually $32-$40 an hour in the DC area and you have to provide food and some supplies (rehab care team will help you get Medicare provided equipment like a hospital bed commode, etc.). It might not be cheaper than a mid range assisted living but it depends on what his needs are.

[Anonymous]

OP here. Thanks to everyone for all the great advice. We were able to finagle a spot at the in hospital advanced rehab program, and my dad is in great hands. It's a dream outcome for us. Covered by Medicare and likely to get him home in a few weeks or less. He is progressing nicely with great PT and OTs.

It was super helpful to hear from everyone and helped me to effectively advocate for my dad.

[Anonymous]

Glad it is working out for you. Try to get him home as soon as circumstances and resources permit. Hospitals are useful but carry their own risks.