What to do when Medicare runs out for rehab

Rehabilitation can be a lifeline, enabling you regain strength, mobility, and confidence after a hospital stay. But what happens when Medicare runs out for rehab? It is a question that can bring stress and uncertainty. Take a breath. You are not alone. Let’s stride through exactly what Medicare covers, identify the gaps, and analyze how you can move forward with confidence and support. 

What to do when Medicare runs out for rehab? 

 First, be aware that Medicare coverage for rehabilitation, especially in a skilled nursing facility or inpatient setting, is limited. Once you have hit Medicare’s limit, such as the 100 days for skilled nursing facility care, you may face significant costs. But this is not the end of the road. Here are the next steps. You can explore Medicaid eligibility, supplemental insurance, home health therapy, outpatient care, and appealing coverage decisions. Let’s unpack everything. 

Who qualifies for Medicare coverage for rehabilitation services, such as physical or occupational therapy? 

To qualify, you need Medicare Part A (hospital insurance) and must meet a few key conditions. For rehab in a skilled nursing facility, you first need a qualifying inpatient hospital stay of at least three consecutive days, not including observation status. Your doctor must then order skilled nursing or therapy services that you need on a daily basis, delivered in a Medicare-certified facility. 

What types of rehabilitation services are covered under Medicare, and which parts of Medicare handle them? 

Medicare Part A generally covers inpatient services and skilled nursing facility rehab following a hospital stay. Under Part A, skilled rehab can enclose physical therapy, occupational therapy, speech therapy, nursing care, and medical supplies. 

Outpatient therapy delivered in clinics, doctors’ offices, or outpatient rehab facilities is covered under Part B. Therapy caps no longer apply, so coverage can continue as long as it is medically necessary. 

How long does Medicare typically cover inpatient rehabilitation stays or care in a skilled nursing facility? 

Most people get a total of 100 days of skilled nursing facility benefits per benefit period. Here’s how it works: 

• Days 1 to 20: Medicare pays in full. 

• Days 21 to 100: You pay a daily coinsurance amount set annually by Medicare. 

 Once those 100 days are used, you are responsible for the full cost until your benefit period ends. 

What are the daily cost-sharing responsibilities after Medicare’s rehab benefits reach their limit? 

After day 20, you will pay a daily coinsurance until day 100. After day 100, Medicare stops paying entirely. If your rehab continues past that point, you will be responsible for all costs. 

Are there exceptions or extensions available for Medicare rehab coverage beyond the standard limits? 

 Medicare does not offer extensions beyond the 100-day limit for skilled nursing facility care in a benefit period. However, if you go 60 days in a row without inpatient skilled nursing or hospital care, a new benefit period begins. This resets your eligibility for another 100-day coverage period; however, you must have a qualifying hospital stay again to utilize it. 

What alternative programs or financial aid options are available once Medicare stops covering rehab? 

 When Medicare runs out for rehab, you still have several paths to consider: 

• Medicaid: If your income and assets are fixed, you may qualify for full coverage in a Medicaid-certified nursing facility. Many skilled nursing facilities accept Medicaid. 

• Medicare Savings Programs: These can help with cost sharing. 

• Medigap (supplemental insurance): Some plans cover coinsurance or even the full costs after Medicare benefits are exhausted. 

• Long-term care insurance: If you have this type of policy, it may cover extended stays beyond Medicare’s limits. 

How can Medicaid or Medicare Advantage plans help when traditional Medicare rehab coverage ends? 

 A Medicare Advantage plan, also known as Part C, may offer extra benefits beyond Original Medicare. These can include waivers for the three-day hospital rule, extended skilled nursing coverage, or lower daily coinsurance rates. 

 Medicaid, for those who qualify, can take over in certified nursing homes even after Medicare stops paying. This can help you stay in the same facility if it accepts both Medicare and Medicaid. 

Can you appeal a Medicare decision that cuts off your rehab coverage? 

Yes, you can appeal. Suppose Medicare ends coverage, and you believe you still meet the medical requirements for skilled rehab. In that case, you can request a fast or standard appeal.  

For Original Medicare, you can work with your local Quality Improvement Organization. If you are in a Medicare Advantage plan, you will follow that plan’s appeal process. 

Does Medicare cover follow-up outpatient therapy services after an inpatient rehab stay ends? 

Yes, Medicare Part B covers outpatient therapy services, such as physical, occupational, or speech therapy, even after skilled nursing facility days have been used up. Medicare may also cover skilled treatment at home under home health benefits if you qualify as homebound and meet specific medical requirements. 

Final thoughts

Recovering from illness, surgery, or injury takes strength and patience. Hitting the limits of Medicare coverage for rehab can be frustrating, but it does not have to mean the end of your progress. With proactive planning, appeals, and support from Medicaid, Medicare, or outpatient services, you can continue the care you need. 

The most crucial step is to know your options before you reach the limit. By understanding how Medicare works and preparing for the next phase of your rehab journey, you can focus less on the bills and more on your recovery. 

You are more than a patient on a chart. You are a person working toward your optimal health, and there are resources available to help you achieve it.

Disclaimer: This article is for informational purposes only. Medicare coverage and costs can vary by region, plan type, and individual circumstances. Always speak directly with your provider or Medicare representative for the most accurate information.

Source: healthcare.gov