5 Sep 2016
Understanding your coverage under Medicare is essential, especially when dealing with a hospitalization. There are so many things to consider, so asking yourself
a few key questions can help. How long will you be in the hospital? What happens when care is needed after you come home? Can you go to rehab? Who will pay for it all? While hospital social workers or case managers are there for support, often times we don’t even know the questions that need asking.
To start, Medicare has a $1,288 deductible for a hospital admission per benefit period. (You may have more than one benefit period in a year if they are separated by 60 consecutive days of no in-patient hospital care.) If you have a traditional supplemental plan, the deductible is likely covered. If you have Medicare Advantage plan, this may be covered but there is still some type of deducible for most plans.
If you need to go to sub-acute rehab, instead of going directly home from the hospital, Medicare requires that you have had at least a 3-day admission in a hospital before they will pay for the sub-acute rehab stay. So if you are in the ER for a couple of days or are in the “observation unit” for any amount of time, and not admitted, you will not qualify for Medicare-covered rehabilitation. This is important to know because non-covered rehab can cost upwards of $450 a day.
If you do meet the hospital admission requirements, then you can go to a sub-acute rehab under Medicare. Traditional Medicare will pay 100% of the cost for the first 20 days. From day 21 through day 100 there is a $157.50 per day co-pay. Some supplemental policies cover this. Some Medicare Advantage plans provide better coverage with lower or no co-pays. Ideally, you should call your plan immediately so you are aware of the potential out-of-pocket costs of a sub-acute rehab stay.
If you are going directly home, you will likely be referred to one of the many Certified Home Health Agencies (CHHA) in the area. Your Medicare coverage will cover these services. But don’t rely solely on them if you have a lot of care needs. They start with a nurse or physical therapy visit within 24-48 hours after your hospital discharge. It can take several days or more for an aide to be in place, and an aide may come only two or three times a week for a couple of hours per visit. You may need to consider arranging for private hire, at least temporarily.
Reaching out to an Elder Care Consultant or Geriatric Care Manager to help navigate these murky waters can be very helpful.