Dear Meredith,
My father was recently hospitalized for a broken hip. Dad’s doctor told us he’d need post-hospital rehab to help him get back on his feet following his stay.
Now we’re trying to figure out how (or even if) the rehab will be covered by his insurance, but it’s been really confusing trying to sort through what’s covered and what’s not. Can you give me any info on how insurance works for rehabilitation after a hospital stay?
-Bill from Columbus, OH
Dear Bill,
Don’t worry — you aren’t the only one left with lots of questions about post-hospital rehabilitation and insurance.
In fact, we get questions about insurance all the time. To help you out, I’ve gathered some of the most common post-hospital rehabilitation insurance coverage questions and answered them below.
Just a quick note—you didn’t mention whether your dad has private insurance or Medicare, so I’ll make sure I touch on both.
Sincerely,
Meredith
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Related: Choosing the Right Rehab Center
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Q: How much therapy will my parent receive after a hospital stay, and will insurance cover it?
A: How much therapy your parent receives depends on their needs. Typically, someone who needs therapy following surgery or hospital stay will get about five days a week of therapy covered by their insurance, with about an hour a day for each necessary discipline (physical, occupational and speech therapy).
Regarding what insurance will cover, each plan is different — some might only cover 30 minutes instead of a full hour in a certain discipline. But generally, 30-60 minutes per discipline five times a week is typical for inpatient post-hospital rehabilitation.
It’s also important to note that how much therapy someone receives can depend on their insurance plan, which leads me to the next question we get a lot.
Q: What services does my parent’s insurance cover during post-hospital care?
A: Again, this depends on the insurance plan. But insurance typically covers therapy, nursing services, meals and activities.
The only thing that might not be included is a physician or specialist visit. However, most people can bill these services to another portion of their insurance.
For example, many who receive rehabilitation services at an Optalis community have either Medicare Part A, Part B or a Medicare replacement plan. Medicare Part A would cover therapy and services, while Medicare Part B would cover physician visits.
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Related: Ask the Expert: How Much Does Post-Surgery Rehab Cost?
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Q: How long will insurance cover my loved one’s stay in inpatient rehabilitation?
A: This can vary depending on your insurance. Most Medicare plans cover up to 100 days of rehab and skilled nursing, given that you meet the guidelines.
Commercial insurance plans are more variable — some have shorter benefit periods than Medicare. For specific timelines, contact an Optalis community today. We can help you by contacting your insurance provider and obtaining the necessary information.
Q: How long will my parent need rehabilitation?
A: This ties into the above question. Just because many insurances offer coverage for 100 days, this doesn’t mean 100 days will be necessary.
Insurance will only cover rehabilitation for as long as someone needs it. You may wonder — “how is that determined?”
Typically, that is determined by updated progress reports sent to the insurance company from the rehab center. The insurance company then reviews the reports and issues what’s known as a “last cover day.”
Trained doctors and nurses work at the insurance companies to determine these dates. But, you do have an appeal option that we can help you with if you disagree with the assessment.
Q: What will my loved one have to pay out of pocket?
A: Most insurance plans do have some sort of daily copay. Usually, those copays start after around 21 days for Medicare or Medicare replacement plans. However, that may start sooner for commercial plans.
Q: Can my parent come from home, or do they need a hospital stay before the insurance covers rehab?
A: Medicare does require a three-night, inpatient hospital stay before becoming eligible for rehab coverage. By contrast, commercial insurance or Medicare replacement plans typically do not require a hospital stay. However, they do require prior authorization.
At Optalis, we can take care of the prior authorization as long as we have the necessary medical information. It’s not uncommon for people to come into rehab from home because sometimes people return home from the hospital too soon.
That actually brings up something else I wanted to address — as mentioned above, Medicare does require a three-night, inpatient hospital stay. However, if someone goes home after such a hospital stay and decides they came home too soon, rehab can be covered by Medicare as long as they’re within 30 days of their qualifying stay.
However, don’t wait too long. The more time that passes from the stay, the more difficult it can be to acquire the necessary information from the hospital.
Q: I’ve heard people mention managed care insurance benefits before. What is that?
A: Managed care insurance benefits are a type of plan that contracts with healthcare providers to provide care at a reduced cost. Many communities like ours accept managed care insurance benefit plans.
Examples of managed care plans include commercial insurance plans like health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Other managed care insurance plans are Medicare Advantage plans and Ohio’s Medicaid Managed Care Insurance Benefit.
To read additional information on managed care insurance benefits, visit this dedicated webpage with helpful content and a section on frequently asked questions.
Questions? Optalis Can Help
I hope those answers helped clear things up for you. If you have any other questions, please contact us.
All of our directors of admission are more than happy to answer insurance questions. Every plan is different, so if you have questions about your plan and what it will cover at an Optalis community, feel free to reach out anytime.
