If you are reading this article — that is, if you got past the title — it probably means you are already somewhat knowledgeable about all the things Medicare can provide for you when it comes to health insurance and all the complexities that go with it: The enrollment periods. The advantage plans. The TV commercials. The seemingly constant inclusion of Medicare in political ads. Medicare is everywhere.

As well it should be. Our country’s over-65 population is at its largest number ever and with advancements in health care, that number will only go up in the future. It is important to know what Medicare covers — but with the average lifespan increasing (absent worldwide pandemics), it may well be more important to understand what Medicare doesn’t cover. 

Unfortunately, dozens of my clients end up in the hospital each year because of both figurative and literal bad breaks from falls in their home. It’s a very familiar pattern, and it is also a good example of the limits of Medicare at the place where the worlds of health care and long-term care meet. These falls often lead to surgery and stays of a week or more in the hospital. Sometimes a debilitating condition or an infection can land a client in the hospital for more than a few days. As we saw during the last few years, potent strains of communicable diseases can have the same power. 

Regardless of the reason, spending three-plus days in a hospital bed may very well require a week of rehabilitation to strengthen those muscles and bones before returning home. Medicare can provide coverage for the hospitalization and the rehab in this example. Following a three-day inpatient hospitalization, Medicare can provide up to 20 days of 100% coverage for rehabilitation in a skilled nursing facility. 

If the length of rehabilitation extends beyond 20 days, Medicare can cover a portion of costs up to the next 80 days (days 21-100) — leaving the patient responsible for a daily co-pay that can add up to thousands of dollars per month. Some Medicare recipients have additional gap coverage that can cover this co-pay, but most people do not. That means that if a loved one has a lengthy rehab stay — say, 80 days total — the final two months (60 days) may cost in excess of $11,000 out of pocket. Still, Medicare’s coverage is quite substantial. 

So what’s the problem? Well, the devil is in the details. You may have noticed that Medicare’s coverage levels vary at stages “up to” the first 20 days and “up to” the next 80 days. If your loved one initially refuses rehab or plateaus in their recovery, Medicare can refuse to cover any additional rehab — whether that is on day 3 or day 93. If your loved one is not ready to go home despite Medicare’s assessment, they may have to pay out-of-pocket for skilled nursing facility treatment going forward. That means daily rates in excess of $575 per day, or $17,000 per month. In addition, Medicare’s rehab coverage kicks in only after the requisite three-day inpatient stay at the hospital. Being placed on observation status, regardless of length of stay, doesn’t count toward the threshold needed to trigger Medicare benefits. 

It is a confusing part of life, and the simple way to remember where the line is drawn is that Medicare covers events from which you can recover. Break a leg? Medicare can cover the hospital visit, the surgery, and the rehab (as long as you are getting better). But if you’re left with a bad leg and your 100% is no longer a “full tank,” so to speak? Medicare will not help with your long-term care realities and needs.

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David A. Kubikian is a principal of the Herzog Law Firm and he concentrates his practice in the areas of Estate Planning, Medicaid Planning/Elder Law, and Estate Administration and Litigation. David prides himself on providing a superior client experience.

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