One of the most frequent questions asked by patients planning for surgery is if their post-operative rehabilitation and physical therapy will be covered by insurance.
Unfortunately, the answer isn’t a simple yes or no. Individual insurance plans will cover various services, but overall most will cover some percentage of your post-op services.
Bridge Care Suites is a Medicare-certified facility, an essential factor for individuals insured through Medicare. Additionally, we are Joint Commission Accredited. Accreditation is a prerequisite for some insurers or third parties to be eligible for reimbursement and participation in managed care plans.
There are two categories of insurance, Private and government-funded (Medicare/Medicaid). Many people are covered under one or both — the following breaks down the general coverage and payments.
Private Insurance Coverage
The Affordable Care Act defines physical therapy and other rehabilitation services as essential health benefits.
Medical necessity is the baseline insurance coverage requirement for physical therapy and post-op rehabilitation. On average, insurance companies will pay approximately 50–75 percent of the cost.
There are three methods by which insurance may provide coverage:
- The first is the deductible and coinsurance method: your insurance plan will have a set deductible amount you must meet and pay before the insurance company begins providing coverage. At this time, you will still be responsible for paying a coinsurance. The coinsurance is a set percentage of medical costs that the insurance company sets. The typical rate is around 20-30 percent.
- The second method is the most simple and straightforward, where you pay a co-pay: if you have a co-pay, the insurance company sets a flat rate that you are responsible for paying at each visit. If you are participating in rehabilitation or physical therapy through an inpatient facility, the co-pay is set at a daily rate.
- The third is the deductible and co-pay method: this is similar to the deductible and coinsurance. Once you reach the deductible amount, insurance will step in and begin its share of coverage. However, you are responsible for paying a copay at each visit or a daily co-pay rate for inpatient stays.
In order to receive coverage from Medicare – on either in- or outpatient rehabilitation, you must be enrolled in Medicare.
There are requirements you must meet to receive premium-free Medicare Part A coverage. In general, there are three specific requirements you must be able to meet:
- you are at least 65 years of age;
- you are a United States citizen or a legal resident for a minimum of five years;
- you are eligible to claim Social Security Retirement, Survivor’s Benefits, or Railroad Retirement Board Benefits.
If you are under 65 years old, you may still qualify if you have received Social Security Disability or Railroad Retirement Board benefits for no less than 24 consecutive months.
You can always visit Medicare’s website to fill out their questionnaire to discover eligibility. If you do not meet the premium-free Medicare Part A coverage requirements, you still have the ability to enroll.
However, the overall cost may be higher and based on your current income or history. At the time of enrollment, you will have the option to enroll in Medicare Part B and Medicare Part D coverage. Everyone must pay a premium for Part B and Part D – costs will vary.
Medicare Part A Requirements & What You Pay For Inpatient Rehabilitation
Your Medicare Part A plan will cover inpatient services. Medicare provides ample coverage, but not without limits and eligibility requirements. First of all, the facility you choose must have a skilled nursing bed that has been deemed Medicare-certified.
Essentially, Medicare must have approved the facility for meeting the quality and care standards set by the Centers for Medicare and Medicaid Services (CMS).
To qualify for inpatient coverage, you must have a qualifying hospital stay or the “three-day rule.”
What is a qualifying hospital stay?
This is enacted when you have been admitted into a hospital as an inpatient for a minimum of three days. The fine-print of this requirement states any time spent in the ER or under observation and the day you are discharged does not count towards the three days. Once you are discharged from the hospital, you must be admitted into the skilled nursing facility within a minimum of 30 days. Furthermore, your doctor must confirm you require daily skilled nursing or therapy.
What you pay will depend on your benefit period, deductible, and the total length of your stay.
Your benefit period begins when you are admitted as an inpatient to the hospital. You are required to a deductible at the beginning of each benefit period. Each period ends after 60 consecutive days without receiving any care as an inpatient.
The first 20 days as an inpatient are 100 percent covered by Medicare (this does not include your deductible). If your stay exceeds this time, your coverage will change. During days 21-100 of your visit, you will be required to pay a daily co-payment; Medicare will continue to cover all other costs.
For inpatient stays lasting 101 days and longer, all costs fall under your responsibility unless you have private insurance or Medicaid to help.
Medicare Part A will cover a semi-private room, your meals, and skilled nursing and skilled therapy services. Private nursing is not covered by Medicare Part A or Part B. Medicare does not provide coverage for an in-room phone or television (if there is a separate charge) and personal items. Medicare will provide coverage for a private room in situations where one is medically necessary.
Medicare Part B Coverage & What You Pay
Upon enrolling for Medicare, you have the option to enroll in Part B at the same time or a later date.
Medicare Part B requires monthly premiums to be paid by everyone. If you choose to register at a later date, you will likely have to pay a penalty fee in addition to a higher premium. Outpatient rehabilitation and physical therapy services are covered under Medicare Part B.
This includes medically necessary doctor’s services, home health services, and durable medical equipment.
Your doctor must certify that physical, occupational, or other forms of rehabilitation therapy are necessary measures of treatment for Medicare to provide coverage. Home health care services are covered under Part B for individuals who are considered homebound.
Depending on the service you need, the amount you pay varies. In general, most services require you to pay a deductible. Once the deductible has been met, you will be responsible for paying around 20 percent of a Medicare-approved amount.
To learn more about services covered under Part B and information regarding costs, you can refer to the “Medicare and You 2022” handbook.
Insurance, Medicare, & Bridge Care Suites
There’s no denying that navigating through what is – or isn’t – covered under your insurance policy can become confusing, especially if you have multiple forms of insurance.
Fortunately, the highly knowledgeable staff at Bridge Care Suites can help you discover the specifics of your insurance plan. Contact the Guest Billing Coordinator for Bridge Care Suites today by phone (217) 787-0000, email, or the online form.
Bridge Care Suites accepts insurance from United Health Care-Preferred Provider, HealthLink, Health Alliance, Blue Cross Blue Shield – State of Illinois, Coventry, and Preferred Provider for UHC.