Skilled Nursing Facility Coverage vs. Inpatient Rehabilitation Facility Coverage Under Medicare
By Howard S. Krooks, Esq., CELA, CAP, Partner, Elder Law Associates PA
Did you know that Medicare offers different coverage for a patient at a skilled nursing facility versus an inpatient rehabilitation facility after a hospital stay? Typically, you may not have much of a say in choosing which type of facility you go to after being in a hospital (a doctor will make this decision). However, you can advocate for yourself with the doctor if you know the differences between the two facilities, and you should have a good understanding of what kind of coverage Medicare provides before you enter a facility for rehab therapy.
What Are the Differences Between an Inpatient Rehabilitation Facility and Skilled Nursing Facility?
An inpatient rehabilitation facility (IRF) is often inside or within a hospital, but it can also be a stand-alone facility where patients can receive intensive physical and occupational therapy for a minimum of three hours per day. The therapy is supervised by doctors and nurses with experience in rehabilitation. To qualify for this kind of facility and care, the patient must require 24-hour-access to doctors and nurses and should be able to handle this type of rigorous activity.
Medicare Part A covers an IRF stay in the same manner as a hospital stay: Medicare pays for 90 days of care per “spell of illness,” plus an extra 60 days of additional lifetime reserve. The spell of illness begins when a patient is first admitted to the facility/hospital until the patient has gone 60 days without being readmitted to a hospital or any other facility of this type. Under Medicare, there is no limit to the number of spells of illness a patient can have, however, to be eligible for Medicare coverage, the patient needs to pay the deductible for the treatment at the facility. The amount of the deductible changes annually for this coverage. In 2020, the deductible for Medicare Part A is $1,408.
After the patient pays the Medicare deductible, the patient will be covered for basically all the hospital or IRF charges during the first 60 days. From day 61 to day 90, the patient will need to pay some of the costs of care, with a coinsurance/copayment amount of $352 per day (2020 amount). After 90 days, the patient’s 60-day lifetime reserve kicks in, however, during these reserve days, the patient would have to pay a copayment amount of $704 per day (2020 amount – the copayment amounts also change annually).
A stand-alone skilled nursing facility (SNF) is in a separate facility from a hospital and provides around-the-clock nursing care as well as rehabilitation therapy, but the therapy is generally not as intense as at an IRF. Medicare coverage for SNF stays is more limited than at an IRF.
At an SNF, Medicare Part A will cover up to 100 days of skilled nursing care per spell of illness. However, starting on day 21 through day 100, the patient is responsible for a daily copayment equal to one-eighth of the initial hospital deductible (in 2020, that amount is $176). The Medicare coverage requirements for a SNF are also stricter than at an IRF.
To qualify for Medicare coverage for a stay at an SNF, the patient must enter the facility no more than 30 days after a hospital stay of at least three days, not counting the day the patient is discharged. Please note, the patient must have been admitted to the hospital rather than under “observation status,” which does not count for Medicare.
In addition, the patient must be receiving skilled care daily at the facility for the same condition that caused the initial hospitalization or a medically related condition to receive Medicare coverage. (This type of care should not be something that can be provided at home or at an outpatient facility). A doctor must order this type of skilled care and it must be provided by or under the supervision of a registered nurse, licensed practical nurse or physical therapist.
It’s important to note that some or all of the deductible and coinsurance amounts for either an IRF or an SNF can be covered by Medigap insurance (Medicare supplemental insurance).
If the patient has not received a skilled level of care, either in an SNF or at a hospital for 60 days or more, a new spell of illness can begin, and the patient can remain in the SNF and qualify for Medicare. Many people are mistakenly under the impression that they need to leave the SNF in order to receive Medicare for any additional spells of illness.
Find Out More About Medicare Coverage
For more information about the 2020 premiums, deductibles and coinsurance amounts for Medicare Part A, you can visit the Centers for Medicare and Medicaid Services at https://www.cms.gov/newsroom/fact-sheets/2020-medicare-parts-b-premiums-and-deductibles. If you have any questions about Medicare coverage and qualifying for a stay at an SNF or IRF, please contact me at 1-800-ELDERCARE or (561) 750-3850 or go to www.elderlawassociates.com for more information.
Howard S. Krooks, Esq., CELA, CAP, is a partner at Elder Law Associates PA, with four offices located in Southeast Florida. Mr. Krooks also is Of Counsel to Amoruso & Amoruso, LLP, in Rye Brook, New York. He splits his time between New York and Florida, where his professional practice is devoted to elder law and trust and estate matters. Mr. Krooks is certified as an Elder Law Attorney by the National Elder Law Foundation and is a past president of the National Academy of Elder Law Attorneys (NAELA), a past president of the New York Chapter of NAELA and serves on the Executive Council of the Florida Bar Elder Law Section as the Substantive Vice Chair. Mr. Krooks has been consistently selected for more than 10 years as a Florida Super Lawyer and a New York Super Lawyer, named a Top 25 Westchester County Attorney, has a 10.0 (Excellent) rating from Avvo and is AV Preeminent®-rated by Martindale-Hubbell. For more information about Mr. Krooks, please visit www.elderlawassociates.com or call 1-800-ELDERLAW or (561) 750-3850.