To receive therapy in a long-term care facility and have it covered by Traditional Medicare, the individual must have been in the hospital for three midnights before transferring to a rehab facility. Sometimes, hospitals keep an individual for a limited period but list their stay as observation, not inpatient. When this happens, if the individual is on Traditional Medicare, they will NOT qualify for Medicare to pay for the rehab stay!
Traditional Medicare will pay up to 100 days. The coverage will be 100% for the first 20 days and 80% from day 21-100. If the individual has supplemental insurance, they will most likely cover the 20% not covered by Medicare. Understand that an individual is not guaranteed 100 days of coverage. This could be at 10 days or go to the 100-day maximum.
Lifetime reserve days are additional days that Medicare will pay for when an individual is in a hospital for more than 90 days. Individuals are limited to a total of 60 reserve days throughout their life.
Medicare Advantage Plans have different requirements regarding the length of hospitalization and when co-pays become effective. However, these plans still offer full or partial coverage for a maximum of 100 days. You need to check your policy to see what your benefits are.
Physical therapy, occupational therapy, and speech therapy are therapies in long-term care. Speech therapy can be included with physical or occupational therapy but cannot stand alone.
Costs for Medicare Coverage
Medicare Part A premium: Most individuals do not pay a monthly premium for Part A.
Medicare Part B premium: The cost for both 2024 is $174.70 monthly, and the Part B deductible is $240 annually—the Part A Hospital deductible is $1632 for each benefit period.
Demand Billing
When an individual’s Medicare days are about to end, the facility must send a Notice of Medicare Provider Non-Service to the individual and their legal representative. If the individual disagrees with the decision to terminate Medicare services, they can request Demand Billing. Demand Billing will trigger a review of the individual’s case to see if they qualify for more coverage. The individual cannot be charged for Medicare Part A services during the review; these reviews are rapid, usually within 24-48 hours. If the decision is in the resident's favor, they can stay in the rehab and continue with the therapy. If the decision is not in the resident's favor, they can appeal further, but a cost may be associated with moving forward.
Cheryl J. Wilson, M.S.
Advocacy 4 Seniors
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