If you have an older loved one who is facing health related issues you likely already know how complicated the Medicare system can be to navigate. A specific coverage issue has created a problem for a number of Medicare recipients recently that you may need to be aware of in the event that your loved one is ever transferred to a skilled nursing facility or rehabilitation center from a hospital.
As a general rule, Medicare benefits do not include coverage for long-term care facilities. There is an exception to that general rule, however, under very specific circumstances. If a Medicare recipient is transferred to a skilled nursing facility or rehabilitation center following a three day stay at a hospital Medicare will cover up to100 days of care at the facility or center assuming all eligibility criteria are met. Medicare will cover the first 20 days at 100 percent. The remaining stay, up to an additional 80 days, is partially covered by Medicare with the recipient being responsible for a co-pay of $148 per day as of October, 2013. Medicare will cover these costs as long as the patient is making progress and/or maintaining his or her skill level as a result of the therapy the patient is receiving at the facility.
While this exception to the general Medicare rule denying coverage of long-term care sounds great, many recipients are being denied coverage despite apparently qualifying. The reason appears to be that hospitals are using a status code that results in Medicare denying coverage. Instead of formally admitting a patient, a hospital has the option to classify the patient as being kept for “observation” for as long as the hospital chooses to do so. If a patient is listed as being kept for observation instead of being admitted and then transferred to a nursing facility or rehabilitation center Medicare will not cover the subsequent stay.
So how can you avoid running into this problem? If you have an elderly loved one who is “admitted” to the hospital, take the time to ask the administration what your loved one’s official status is at the hospital. If he or she has not been listed as formally admitted, ask them to change the status to reflect admission. If you do not get anywhere yourself, consult with your family or primary care physician and ask them to request a formal admission from the hospital. By ensuring that your loved one is formally admitted you will dramatically increase the chance that Medicare will pay for a subsequent stay in a nursing facility or rehab center if one becomes necessary.