Q: Rec-ently, my mother fell on the ice and broke her leg. While she was in the hospital she developed an infection which lengthened her stay. She will soon be discharged from the hospital; according to her doctor she will need extended rehabilitation therapy. I am so confused about which facility is best for her and what Medicare will pay. Can you help me understand this?
A: The two major questions you have are somewhat related but it will probably make more sense if each one is addressed separately. The first issue regards Medicare payment, essentially how much will be paid and for how long.
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. 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, then the patient is responsible for a co-payment of $152 (2014 rate) for days 21-100. This is strictly the payment rate not a guarantee an individual will be covered for the maximum amount of time. If the patient has a Medigap policy or is a member of a Medicare Advantage Plan additional coverage of costs may be available.
Patients are continuously evaluated to monitor their progress and determine if they have the potential for further progress. 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.