Will Medicare cover outpatient rehabilitation?

DEAR MARCI: I was recently admitted to a comprehensive outpatient rehabilitation facility. Will original Medicare cover the services I receive at this facility?

MARCUS

DEAR MARCUS: Medicare may cover certain items and services you receive at a Comprehensive Outpatient Rehabilitation Facility, which is a medical facility that provides outpatient diagnostic, therapeutic and restorative services for the rehabilitation of your injury, disability or sickness. This care is commonly referred to as outpatient rehabilitation care.

In order to receive services at a CORF, your doctor must create a treatment plan and review it at least every 60 days.

Medicare will typically cover the following items and services you receive at a CORF:

•Doctors’ services.

•Physical, occupational and respiratory therapy, and speech-language pathology services.

•Prosthetic and orthotic devices, including testing, fitting or training in the use of these devices.

•Social and psychological services if they relate to and are needed to carry out the rehabilitation treatment.

•Nursing care provided by or under the supervision of a registered professional nurse.

•Supplies and durable medical equipment.

Generally, there is one combined bill for all of the CORF care you receive. Original Medicare will pay 80 percent of the cost of the CORF care, and you or your supplemental insurance will be responsible for the remaining 20 percent.

However, a separate charge will apply if you received medical equipment or supplies you receive from the CORF. Medicare will pay 80 percent of the cost of this additional bill and you must pay 20 percent coinsurance.

If you are in a Medicare private health plan, also known as a Medicare Advantage plan, you should call your plan to see what costs and rules apply to CORF care.

DEAR MARCI: My grandmother is homebound and needs a home health aide to help her bathe, dress and use the bathroom. Will Medicare pay for her home health aide?

KRISTINE

DEAR KRISTINE: Medicare will only pay for a home health aide if your grandmother meets all of the requirements necessary to qualify for the Medicare home care benefit. To qualify for the Medicare home care benefit, your grandmother must:

•Be homebound, meaning it is extremely difficult for her to leave the home and she requires help to do so.

•Need skilled nursing care on a part-time basis or skilled therapy services. Skilled care is when the care can only be safely administered by a licensed nurse or therapist.

•Have a face-to-face visit with a health care professional within 60 days before she gets home care or 30 days after she gets care. Her doctor may sign a home health certification, verifying that she has had this visit and that she qualifies for home care because she is homebound and needs skilled care.

•Receive certified care from a Medicare-certified home health agency.

If your grandmother fulfills all of these requirements, Medicare will pay for skilled care in her home as well as care from a home health aide. A home health aide will provide personal care services, such as help with bathing, using the toilet and dressing.

Keep in mind that her doctor will need to approve her plan of care every 60 days. As long as your grandmother continues to meet Medicare coverage rules, Medicare should continue to cover her care.

DEAR MARCI: I’m currently in the doughnut hole, and I can’t afford my prescription drugs. I don’t qualify for Extra Help, but I’ve heard about some patient assistance programs that might be able to help me. How can I learn more about these programs?

DAVE

DEAR DAVE: Patient Assistance Programs are programs that offer low-cost or free prescription drugs to people with low incomes. These programs are offered by drug companies, and each program has its own eligibility requirements. Even if you don’t qualify for Extra Help, the federal program that helps pay for your drugs, you may qualify for a PAP.

Keep in mind that while many PAPs will not accept people with Part D, some do. If you are eligible for a PAP, your medication may be sent to your home, your doctor’s office or a local pharmacy, depending on the program.

For a list of available PAPs, you can visit www.needy meds.org or www.rxassist.org. Search the name of the medication you are taking to find a program that offers this drug. Since each PAP is different, you may be required to pay a copayment.

What you pay will count toward meeting your out-of-pocket limit ($4,700 in 2012) as long as you submit your receipts, and any other required documentation, to your plan. Bear in mind that what the PAP pays for your prescription drugs will not count toward the out-of-pocket limit that you must reach to get out of the doughnut hole. If you are interested in a specific PAP, call the program to find out how it works.

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Marci’s Medicare Answers is a service of the Medicare Rights Center (www.medicarerights.org), the nation’s largest independent source of information and assistance for people with Medicare. To speak with a counselor, call 800-333-4114.

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