August
2nd, 2019
Hospital patients who need additional care after being
discharged from the hospital are usually sent to either an inpatient
rehabilitation facility (IRF) or a skilled nursing facility (SNF). Although
these facilities may look similar from the outside, Medicare offers very
different coverage for each. While you may not have complete say in where you
go after a hospital stay, understanding the difference between the two
facilities can help you advocate for what you need and know what to expect with
regard to Medicare coverage.
An IRF can be either part of a hospital or a stand-alone facility that offers intensive physical and occupational therapy under the supervision of a doctor and nurses. IRFs offer a minimum of three hours a day of rehabilitation therapy. An SNF, on the other hand, provides full-time nursing care. Patients also receive physical and occupational therapy, but the care is generally less intensive and specialized than in an IRF.
An IRF can be either part of a hospital or a stand-alone facility that offers intensive physical and occupational therapy under the supervision of a doctor and nurses. IRFs offer a minimum of three hours a day of rehabilitation therapy. An SNF, on the other hand, provides full-time nursing care. Patients also receive physical and occupational therapy, but the care is generally less intensive and specialized than in an IRF.
Medicare Part A covers a stay in an IRF in the same way
it covers hospital stays. Medicare pays for 90 days of hospital care per
"spell of illness," plus an additional lifetime reserve of 60 days. A
single "spell of illness" begins when the patient is admitted to a
hospital or other covered facility, and ends when the patient has gone 60 days
without being readmitted to a hospital or other facility. There is no limit on
the number of spells of illness. However, the patient must satisfy a deductible
before Medicare begins paying for treatment. This deductible, which changes
annually, is $1,364 in 2019.
After the deductible is satisfied, Medicare will
pay for virtually all hospital charges during the first 60 days of a
recipient's hospital stay. If the hospital stay extends beyond 60 days, the
Medicare beneficiary begins shouldering more of the cost of his or her care.
From day 61 through day 90, the patient pays a coinsurance of $341 a day in
2019. Beyond the 90th day, the patient begins to tap into his or her 60-day
lifetime reserve. During hospital stays covered by these reserve days,
beneficiaries must pay a coinsurance of $682 per day in 2019.
To qualify for care in an IRF, you must need
24-hour access to a doctor and a nurse with experience in rehabilitation. You
must also be able to handle three hours of therapy a day (although there can be
exceptions).
SNFs and Medicare
Medicare's coverage of skilled nursing care is more limited. Medicare Part A
covers up to 100 days of "skilled nursing" care per spell of illness.
Beginning on day 21 of the nursing home stay, there is a copayment equal to
one-eighth of the initial hospital deductible ($170.50 a day in 2019). However,
the conditions for obtaining Medicare coverage of a nursing home stay are quite
stringent. Here are the main requirements:
·
The
Medicare recipient must enter the nursing home no more than 30 days after a
hospital stay (meaning admission as an inpatient; "observation status" does not count) that itself lasted
for at least three days (not counting the day of discharge).
·
The
care provided in the nursing home must be for the same condition that caused
the hospitalization (or a condition medically related to it).
·
The
patient must receive a "skilled" level of care in the nursing
facility that cannot be provided at home or on an outpatient basis. In order to
be considered "skilled," nursing care must be ordered by a physician
and delivered by, or under the supervision of, a professional such as a
physical therapist, registered nurse or licensed practical nurse. Moreover,
such care must be delivered on a daily basis. (Few nursing home residents
receive this level of care.)
A new spell of illness can begin if the
patient has not received skilled care, either in an SNF or in a hospital, for a
period of 60 consecutive days. The patient can remain in the SNF and still
qualify as long as he or she does not receive a skilled level of care during
that 60 days.
Keep in mind that some or all of Medicare’s
deductibles and co-payments for both IRF and SNF care may be covered by
Medicare supplemental insurance, also called Medigap coverage.
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