Rehabilitation and You

Understanding Your Benefits

Being hospitalized can be an overwhelming experience and thinking about insurance coverage during this time can be daunting. Many times patients are ready to be discharged from the hospital, but are not quite ready to transition back home due to weakness and safety concerns. A rehabilitation setting is a good stepping-stone where someone can work with a variety of therapy services to improve strength and stability before heading home to regular daily activities. Whether you have traditional Medicare, a Medicare replacement plan, or a privately purchased health insurance policy, you may be entitled to rehabilitation benefits following a hospital stay.

With the increasing number of Medicare replacement plans, coordinating rehabilitation following a hospital stay can be more difficult. Traditional Medicare allows someone to go to rehabilitation following a three night qualifying hospital stay and therapy orders. There is no pre-certification required. However, private insurance plans and Medicare replacement plans usually require the rehabilitation facility to pre-certify benefits. It is important that the rehabilitation facility gets prior authorization for your rehabilitation stay and that you are made aware of the certification number and any co-pays you the patient may be required to pay. Most rehabilitation centers have contracts with insurance companies that allow them to be in-network with the insurance carrier. This means that the rehabilitation center accepts payment in full from the insurance carrier and usually there is no co-payment due from the patient. However, if you elect to go to a rehabilitation center that is out of network with your insurance, you may be responsible for a large co-pay upon discharge. In addition, most private insurance carriers require that your deductible be met before they begin payment. Usually deductibles are met in the hospital stay period so in most cases the rehabilitation center would be covered fully.

While Medicare A patients are required to have a three night qualifying stay in the hospital prior to rehab, some private insurance or Medicare replacement policies offer rehabilitation with no prior hospital stay required. And some policies cover more days in a rehabilitation facility than traditional Medicare. It is important that the rehabilitation center has a staff member who works with your insurance company to obtain the proper preauthorization and help ensure your stay is eligible for coverage. Often times insurance companies request periodic review of inpatient rehabilitation cases to determine if they feel coverage should continue. The rehabilitation center should work closely with therapy to communicate the needs of each patient to their insurance to ensure that coverage is able to continue as long as there is progress to be met toward each patient’s individualized goals.

Medicare benefits, Medicare replacement plans and private insurance benefits are a difficult road to travel. It is important that you understand your own policy and what benefits are available to you. It is also important that the rehabilitation center that will be treating you is educated and informed on the most up to date changes in the industry.

Linda Smith is the marketing director at 
LutheranHome.org in Arlington Heights, Illinois.