by: Tammy Gonzales

One of the most frustrating events for individuals facing rehabilitation is thinking that their insurance is going to pay for everything and finding out that their insurance will not pay for the complete services required for a successful rehabilitation.

Nursing home skilled units want to be assured that the necessary steps will be taken to assure that they will be paid. Nursing homes are most familiar with Original Medicare, Medicare Advantage Plans, Medicare Managed Care Plans, Medicare Preferred Provider Organization Plans, Medicare Private Fee-for-Service Plans, Medicare Specialty Plans, federal employee health program, military health program and railroad retirement programs. If your patient has one of these, they will be highly considered once that payer source is verified.

Medicare Part A is the primary source of insurance that will pay for a skilled nursing home stay. Medicare pays 100% of day 1 through day 20 and from day 21 up to day 100 Medicare will pay everything less $114.00 per day co-pay as long as the resident is making progress towards their rehabilitation goals.

If, Medicare is managed through a HMO (Health Management Organization) it usually pays 100% of the rehabilitation stay. The HMO determines the length of stay by the assessments provided to them by the nursing home rehabilitation staff and the level of independence required where the resident will reside after their rehabilitation stay. The HMO utilizes a Nurse Case Manager and a Medical Director who is a physician to make this determination.

Secondary insurances with Medicare Supplemental Coverage will usually pay the $114.00 per day co-pay from day 21 through day 30 up to day 100 depending upon the tier level of the insurance plan and some tiers will some times pay up to 120 days. It is important for you to know what your insurance will cover.

If you have the resources you can of course pay the Medicare $114.00 per day co-pay privately.

Most states offer a Medicaid Program for individuals who meet the financial eligibility and medical need criteria. Please contact your State's Department of Human Services Income Support Division (local Medicaid office) to see if you or your loved one meets the criteria for assistance. Most individuals fear that they may loose their home or all of their income and assets if they apply for assistance. There are laws and regulations in each state that provides Medicaid to protect the home or homestead and to protect the spouse from poverty. There are also attorney's that specialize in Elder Law that can help you protect your income and assets and plan for the transition to State Medicaid Assistance when you or your loved ones resources become exhausted.

Nursing homes generate income from providing rehabilitation services to keep financially afloat. They check to see that they will make a profit from providing the patient the services they need. That means that everything the patient needs in the way of treatments, therapy and medications must be covered by your insurance before they agree to accept a patient from a hospital.

The nursing home will also want to get an understanding of the patient's cognitive status and psycho/social-well-being to see that they are appropriate for their facility unless they have a contract with the discharging hospital. Keep in mind that not all nursing homes are adapted to serve all types of patients. If you or loved one has some behavioral issues, related to dementia, Alzheimer's disease or psychiatric problems they may not be accepted for admission. You may need to find a nursing home that specializes for those types of paient needs.

Understanding your insurance benefits and your needs will get you the services you require for a successful rehabilitation stay.