Does Medicare Cover Long-Term Acute Care?

Long-Term Acute Care (LTAC) facilities provide specialized services for individuals with complex medical challenges. They offer prolonged medical attention, bridging the gap between intensive hospital care and less intensive settings or home. This article clarifies Medicare coverage for long-term acute care.

Understanding Long-Term Acute Care

Long-Term Acute Care hospitals (LTACs) are specialized inpatient facilities for patients with severe medical conditions requiring an extended hospital stay. These patients need intensive medical care beyond what a general acute care hospital provides long-term. The average length of stay in an LTAC is more than 25 days.

LTACs focus on medically complex individuals, often transferring from intensive care units (ICUs) or other acute care settings. Patients commonly admitted need prolonged mechanical ventilation, complex wound management, or extensive rehabilitation following severe illness or injury. These facilities treat conditions such as respiratory failure, severe infections, and multi-organ system failures.

An LTAC environment is similar to a traditional hospital, with advanced medical technology and healthcare providers. This includes physicians, nurses, and therapists who manage multiple co-morbidities and facilitate recovery. The goal is to stabilize the patient’s condition and improve functional independence for discharge.

Medicare Coverage Criteria for Long-Term Acute Care

Medicare Part A covers services received in a Long-Term Acute Care hospital. For Medicare to cover an LTAC stay, specific medical necessity criteria must be met, requiring hospital-level care for an extended duration. This coverage includes inpatient hospital services and supplies:
Semi-private room
Meals
Nursing care
Medications administered during the stay

A patient must demonstrate a continued need for daily skilled nursing care or therapy services. This often means the patient’s condition is too complex for a skilled nursing facility or rehabilitation center. Medical documentation must support the necessity of ongoing physician intervention and intensive treatment.

Medicare has criteria related to a patient’s prior hospitalization. Full Medicare payment to the LTAC requires the patient to have spent at least three days in an intensive care unit (ICU) before transfer. Alternatively, patients may qualify if they receive prolonged mechanical ventilation for more than 96 hours during their LTAC stay.

Physician certification of medical necessity is a requirement for LTAC admission. The expectation is that the patient’s condition will measurably improve or that they require continued complex medical management to prevent decline. This ensures LTAC services are used appropriately.

Medicare Cost-Sharing for Long-Term Acute Care

Medicare Part A coverage for Long-Term Acute Care hospital stays operates under a benefit period structure. A benefit period begins the day a patient is admitted as an inpatient to a hospital or skilled nursing facility and ends when they have not received inpatient hospital or skilled nursing care for 60 consecutive days. There is no limit to the number of benefit periods a beneficiary can have.

For each benefit period, beneficiaries are responsible for a Part A deductible of $1,676. This covers the patient’s share of costs for the first 60 days of Medicare-covered inpatient hospital care within a benefit period. If a patient transfers to an LTAC within 60 days of discharge from a prior hospital stay, they do not pay a second deductible for the LTAC admission.

Beyond the initial 60 days, daily coinsurance amounts apply. For days 61 through 90 of an LTAC stay within a benefit period, the coinsurance amount is $419 per day. If the stay extends beyond 90 days, beneficiaries can utilize their 60 lifetime reserve days. The coinsurance for each lifetime reserve day used is $838 per day.

Once all lifetime reserve days are exhausted, the beneficiary becomes responsible for all costs of the LTAC stay. These cost-sharing amounts are distinct from charges for physician services, which Medicare Part B covers with separate deductibles and coinsurance.

Navigating the Medicare LTAC Process

Securing Medicare coverage for an LTAC stay involves procedural steps once medical necessity is established. The process often begins with a referral from an acute care hospital, where discharge planners or care coordinators assist. These professionals help identify appropriate LTAC facilities and facilitate transfer.

Medicare or its contractors may conduct pre-authorization or medical reviews to confirm the ongoing medical necessity of an LTAC stay. This review verifies the patient continues to meet criteria for hospital-level care and that the LTAC is the most appropriate setting. Thorough documentation, including physician orders and medical records, is essential.

If Medicare denies coverage for an LTAC stay, beneficiaries have the right to appeal the decision. The appeal process involves several levels, beginning with initial reconsideration. If the denial is upheld, further appeals can be pursued, leading to a hearing before an administrative law judge. Understanding these steps is important for patients and their advocates to challenge denials.

Maintaining detailed records of medical evaluations, treatment plans, and communication with healthcare providers and Medicare is crucial. This documentation supports the patient’s case during any reviews or appeals. While administrative aspects can seem complex, following established procedures helps ensure coverage for necessary LTAC services.