Medicare Cap or Daily Limit?

Posted by Mary Skinner

Question:
I have a client who became a quadriplegic after a motor vehicle accident. He is in an in-patient rehab facility. Medicare advised that he is approaching his $1 million cap and will have to pay for future in-patient care – they have to start paying $20,000 per month going forward, as he is approaching 100 days.

If there is a cap or daily limit, does it only apply to the in-patient rehab facility? He happens to live one mile from the facility. If he has to move home, will Medicare pay for outpatient rehab at the same facility? Will they pay for transportation? Will they pay for a home health aide?

-New York Attorney

Answer:
Medicare covers certain skilled care services that are needed daily on a short-term basis (up to 100 days) in a Medicare-certified skilled nursing facility. Medicare will cover skilled care only if there is a qualifying hospital stay. This means an inpatient hospital stay of three consecutive days or more, not including the day of discharge. Admission to the SNF must be within a short time (generally 30 days) of leaving the hospital and require skilled services related to the hospital stay. After discharge from the SNF, if there is another admission to the same or another SNF within 30 days, another three-day qualifying hospital stay is not necessary to get additional SNF benefits.

The benefit period payments are as follows:
Days 1 – 20: $0 for each day
Days 21 – 100: $128 for each day
Days over 101: 100%

A benefit period begins the day of admission to the hospital or skilled nursing facility. The benefit period ends when there has been no hospital care (or skilled care in a SNF) for 60 days in a row. If there is an admission to a hospital after one benefit period has ended, a new benefit period begins. The inpatient hospital deductible for each benefit period applies. There is no limit to the number of benefit periods you can have.

Additionally, if a beneficiary leaves the Medicare certified part of the SNF then therapy services in the While you are in the Medicare-certified part of the facility, your therapy services in the non-certified part of the facility ARE LIMITED to a specific dollar amount per year UNLESS they are therapy services are from an outpatient hospital.

With that said, if the client could move home, Medicare will pay for the outpatient therapy, but there are caps on outpatient therapy. For physical therapy and speech language pathology services combined, the limit on incurred expenses is $1810 for calendar year 2008. For occupational therapy services, the limit is $1810 per year. The 2009 caps will be slightly higher.
Medicare only pays for ambulance transportation.

Medicare will help pay for home care however there are limits on the number of days per wk or hours per day. In addition, the attending physician certifies that the beneficiary is homebound, meaning it takes a considerable and taxing effort to leave the home; and they need skilled physical, speech or occupational therapy services, or skilled nursing on an intermittent (less than seven days a week) or part-time(less than eight hours a day) basis. If only skilled nursing is required the beneficiary must either need it fewer than seven days a week (even as little as once every 60 to 90 days) or daily (seven days a week) for a short period of time (usually two to three weeks); and a doctor certifies the need for home care, and care is received from a Medicare-certified home health agency (HHA).