When Medicare Ends

When a loved one ends up in a nursing home for rehabilitation, the entire family is justifiably concerned about who will pay for that care, because cost of care can easily be $350 per day, and with rehabilitation services, much more.

The first thing to know, is that if the patient has had a three day hospital stay as an admitted patient prior to entering the nursing home, Medicare will pay for the stay and the rehabilitation, subject to limits. Here is how it works.

The first 20 days are paid 100%. The next 80 days are paid partially, but there is a co-pay of $141.50 per day. For many people, their Supplemental insurance covers that co-pay. So if you have a Supplemental policy, and everyone should, the policy will cover that quite substantial co-pay.

But there is a catch that is seldom understood. Medicare will only pay if the patient is meeting certain guidelines relating to progress in rehabilitation. If the patient gives up trying to work at rehabilitation, or if the therapists and social workers decide that continuing therapy will not improve the patient's ability to function, then the patient will be said to have "plateaued", and Medicare will be cut off, even if the 100 days has not run. And when Medicare cuts off, the Supplemental insurance also cuts off, so that means the patient is a full private pay patient at $10,000 to $13,000 per month.

Because of those rules, the family must encourage the facility and the patient, to give every reasonable effort at therapy and rehabilitation so that Medicare and the Supplement will not be cut off before the 100 day limit.

What happens if you successfully rehab and go home, and end up back in the hospital a couple of months later? The 100 day clock will reset and you will get another 100 days if there has been a 60 day gap between leaving the nursing home and the subsequent hospital admission. This is not unlimited, as there is a lifetime limit, but that is rarely a limit that anyone reaches.

The practical advice here is to have a Supplemental "Medigap" insurance policy, and if a family member does need rehabilitation, give every encouragement to the family member, and to the therapists, to continue working at the various therapies needed until it is clear there will be no further improvement. And if the patient does not have a "Medigap" policy, see an Elder Law Attorney right away to determine what must be done to have Medicaid cover the co-pay.