What to do When Medicare Runs Out for Rehab

When seeking treatment for addiction the last thing you, or your loved one, needs to focus on is limitations on Medicare benefits. There are various options to consider when evaluating your options for treatment. Our blog provides an overview of Medicare benefits, what is covered, what isn’t covered, and what to do when Medicare runs out for rehab.

Who is Eligible for Medicare?

Medicare provides a range of health insurance benefits to qualifying Americans. As a federal health insurance program, those who are eligible for Medicare include:

• Individuals over the age of 65
• People with a disability
• End stage kidney disease
• ALS (or Lou Gehrig’s disease)

Medicare insurance is made up of four parts:

1. Part A: Hospital Insurance. This part is free, and you qualify if you already get retirement or disability benefits from Social Security, are 65 and older, or have already qualified (or your spouse has qualified) for Medicare).
2. Part B: Medicare Insurance – this requires a premium each month depending on your income, or it can be deducted from other benefits.
3. Part C: Medicare Advantage Plans – these monthly premiums vary depending on the plan.
4. Part D: Drug Coverage – these also vary depending on the plan you join. 

What Does/Doesn’t Medicare Cover for Rehab?

Part A (hospital insurance) covers medically necessary rehabilitation, such as an inpatient treatment center. However, your doctor must certify that “you have a medical condition that requires intensive rehabilitation, continued medical supervision, and coordinated care that comes from your doctors and therapists working together.” There are various costs that Medicare does and does not cover.

What Medicare Covers

Medicare covers inpatient rehabilitation costs that include:

• Rehabilitation services
• A semi-private room
• Meals
• Nursing services
• Prescription drugs
• Other hospital services and supplies
• Inpatient doctor’s services are covered (Under Medicare Part B)

Medicare Does Not Cover

• Private duty nursing
• A phone or television in your room – if these are billed separately
• Personal items such as toothpaste, socks, or razors
• A private room, unless medically necessary

How Long Do Benefits Last?

Medicare covers a rehab facility for up to 90 days per benefit period. However, you must first meet a deductible before Medicare covers 100 percent of the first 60 days of treatment and limited costs after that. This looks like: 

• Days 1 to 60: $1,632 – but you do not have to pay this if you have already paid for deductible care in a prior hospitalization within the same benefit period. For example, if you transferred from an acute care hospital
• Days 61 to 90: a daily $408 co-payment 
• Days 91 and beyond: $816 per each “lifetime reserve day” after day 90 (you are allowed 60 reserve days over your lifetime)
• After lifetime reserve days: you must pay all costs

What to Do When Medicare Runs Out 

There are various options available to you if your Medicare benefits run out, including: 

• Medicare supplemental insurance: also called Medigap, this additional insurance policy can help with the parts of treatment that weren’t covered and even your Part A deductible, as well as additional out-of-pocket expenses
• Medicaid: a federal-state health insurance program that can cover costs Medicare won’t. Typically costs that Medicare has rejected will be transferred to Medicaid and these will be paid after you meet your deductible.
• Grants: you may be eligible to apply for certain grants to fund your treatment if you are uninsured or underinsured. For example, SAMHSA provides Block Grants for community mental health treatment. You’ll want to check with your state health department to see where these have been awarded, what services are covered, and any other grants you may be eligible for.
• Payment plans: the rehabilitation program may offer payment plans for any costs Medicare and/or Medicaid won’t cover. Speak to the treatment center payment specialist who should be able to walk you through those options.
• Sliding scale payments: some treatment centers offer sliding scale payment options to low income individuals. You’ll want to speak to the rehab admissions advisor to see if this option is available.
• Scholarships: some rehabs offer scholarship options, and you can check this with their admissions team when evaluating different payment choices.
• Financing: often treatment centers will offer a financing option to individuals if their insurance leaves uncovered costs. Ask their finance department for more information about your options. 

If you or someone you love is experiencing a substance use disorder, help is available. Call 800-914-7089 (Who Answers?) today to learn about your treatment options.