Q: I recently fell and broke my hip. I am now being discharged from the hospital to a rehabilitation facility, will Medicare pay for my stay?
A: As you may know, Medicare will pay for a patient to receive rehabilitation in a facility if they have a qualifying stay in a hospital, i.e. being admitted to the hospital for two nights. The first twenty days of rehabilitation are completely covered by Medicare. The twenty first day through the one hundredth day will have a co-payment of $170.50 per day. Your Medicare Advantage plan or Medigap Supplemental Insurance plan may pay some or all of this co-payment. You should review your current coverage to be sure that it suits your needs.
At any point during your rehabilitation, the facility can make a determination that you are no longer eligible to receive the remainder of your “100 days”. You have the right to appeal this determination. The facility is required to give written notice that they believe Medicare will no longer cover the cost of the stay. This comes as a “Notice of Medicare Non-Coverage.” This notice explains the mechanics of filing an appeal. In order to make an effective appeal, it is important to know the appropriate standard that the law requires the facility use in making a determination. Oftentimes patients are told that they have “plateaued”. This standard is inconsistent with Federal Medicare regulations.
In 2011, a Federal Court case was decided on this issue. In that case, Medicare skilled nursing service recipients, challenged the failure to improve standard. The settlement agreement by the parties rejected the failure to improve standard and stipulated that the standard for terminating services is not whether the patient’s condition is likely to improve, but rather whether the condition will worsen if services are terminated. Therefore, skilled services should be continued so long as skilled therapies are needed to maintain the patient’s ability to perform routine activities of daily living or to prevent deterioration of the patient’s condition. This is the represents the current legal standard for denying skilled nursing coverage under Medicare.
Even though this issue was settled by the courts years ago, many patients are finding it is not being followed by facilities. It is important for the patient and their advocates to know the proper standard so they can make an appropriate appeal. On February 2, 2017, a new Federal court decision stated that the standard is established but it is not being adhered to by facilities. The decision is requiring that an educational campaign be enacted so professionals at facilities and individual Medicare recipients are aware of the appropriate regulations. The plan will include a Centers for Medicare and Medicaid Services website dedicated to this issue and the explanation of the appropriate standard.
Receiving the maximum amount of rehabilitation days possible is the right of all Medicare recipients.
-Nancy Burner Esq. and Britt Burner, Esq.