Ask the Expert: Medicare’s 100-Day Rule vs. Long-Term Care

Q. My 71-year old father, Joe, had a stroke and was hospitalized for a week and a half. When he was discharged, he was moved to a rehabilitation facility for therapy, and Medicare has been paying for his therapy there for 2 weeks. When it comes to his in-patient therapy, what is covered and when does my father have to pay out-of-pocket? What if he comes home and receives outpatient rehabilitative therapy? Will it be covered by Medicare, as well?

Also, my dad gets sick often and falls a lot. What if something else happens and he needs to go back to the hospital and/or rehabilitation facility in the future? Does the Medicare benefit period “reset” annually or within a certain number of days? Lastly, when the care provided is no longer enough, how can we plan in case he needs long-term nursing home care in the future?

A. In your father’s rehabilitation facility, Medicare will cover the cost of a semi-private room, meals, skilled nursing and rehabilitative services, and medically necessary supplies. Medicare covers 100% of these costs for the first 20 days. Beginning on day 21 of his stay, there is a co-payment of $152 a day (in 2014). This co-payment may be covered by a Medicare Supplement policy (also called a “Medigap” policy).

When it comes to rehabilitation services, Medicare works by “benefit periods” rather than on an annual basis like most health insurance. A benefit period is 60 days. If a break in skilled care lasts for at least 60 days in a row, this ends the current benefit period and renews his skilled nursing and rehabilitative services benefits for another 100 days.

Keep in mind that Medicare only covers “acute” rehabilitative care as opposed to custodial care. This means it covers care only for people who are getting acute rehabilitation and are likely to recover from their conditions, not care for people who need ongoing help with performing everyday activities, such as bathing or dressing.

You asked about home health care and whether it is covered by Medicare. It is, when:

It is under a “plan of care” ordered by a doctor.

He must receive the services from a home health agency that is approved by the Medicare program.

He may also get care in an adult day-care program that is Medicare approved and state certified to provide adult day care services.
There is a skilled need requiring frequent visits by either a therapist, LPN or RN.
The patient must be homebound, meaning it would be very difficult to leave the home during the period of recovery.

As part of the plan of care, aides may also be provided to help with occasional bathing, dressing, transferring, toileting, incontinence or feeding. Medicare part B may also cover certain durable medical equipment for home care such as bed rails, walker, etc. Learn more at the medicare.gov website.

You asked what you should do if your father needs long-term care down the road. It is important to understand that Medicare, the public health insurance system for seniors over 65 and disabled adults, does not pay one penny for long-term care. Medicare only pays for medical care delivered by doctors and hospitals, and in certain cases short-term rehabilitation which might take place in a nursing home. In addition, when it comes to Medicaid, it gets very complicated to complete and file the application and, in most cases, it takes an experienced Elder Law firm, such as the Farr Law Firm, to help protect your assets first and then file for Medicaid.

Nursing homes in Northern Virginia cost $9-12,000 a month (less in Fredericksburg). To protect your family’s hard earned money and assets from these catastrophic costs, the best time for your father to create his long-term care strategy is NOW. Generally, the earlier someone plans for long-term care needs, the better. But it is never too late to begin preparing. Even if your were father were already in a nursing home receiving long-term care, it would not be too late to do Long-term Care Planning, also called Lifecare Planning and Medicaid Asset Protection Planning.

If you have a loved one who is nearing the need for long-term care or already receiving long-term care or if you have not done Long-Term Care Planning, Estate Planning or Incapacity Planning (or had your Planning documents reviewed in the past several years), please call The Fairfax and Fredericksburg Long-Term Care Planning Law Firm of Evan H. Farr, P.C. at 703-691-1888 to make an appointment for a consultation.

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