Medicare Waiver Streamlines Path to Rehabilitation Care

by The Maplewood

Does your loved one require a nursing home stay for rehabilitation? They may qualify for a special waiver, allowing them to avoid a hospital stay first.

Medicare typically requires a three-day inpatient hospital stay before covering the costs of rehabilitation at a skilled nursing facility (SNF). For example, if your spouse needed rehab after being seen in a hospital emergency room, he/she would be required to stay in the hospital for at least three days before he/she could transfer to a nursing home and receive Medicare benefits.

Because it’s important to keep hospital beds open for COVID-19 patients right now, The Centers for Medicare and Medicaid Services (CMS) is releasing waivers (called “1135 waivers”) that allow patients to go directly to a nursing home without a three-day hospital stay.

To continue the example above, receiving a waiver could allow your spouse to skip an extended hospital stay and move right into a nursing home after their surgery was performed.

According to CMS, you are eligible to use this benefit if:

  1. You do not already reside in a nursing home or SNF for long-term care
  2. You meet all other CMS criteria for SNF admission, including:
    • being medically stable
    • having confirmed diagnoses
    • not requiring an inpatient hospital evaluation or treatment
    • having an identified skilled nursing or rehabilitation need that cannot be provided on an outpatient basis or through home health services.

However, there is one caveat: if your Medicare benefit is administered by a third party (Preferred Care, Excellus, United…) you will want to call the subscriber desk and see if you qualify for the waiver under their plan. A third party payer will often pursue a different care plan, like sending a patient home with services, instead of covering the cost of rehab in a skilled nursing facility.

Of course, both options can lead to good results, but a recent study found skilled nursing facilities do a better at preventing readmissions when compared to in-home care1. The study examined patients after they were discharged from the hospital, revealing that that in-home care led to a “significantly higher hospital readmission rate.”

While the cost savings of in-home care are certainly worthwhile in some situations, be sure to consider your options before making a choice.

To summarize, if your loved one has a qualifying medical condition that can be treated by a skilled nursing facility, the temporary 1135 waiver could make a difference in how their recovery is handled. The waiver doesn’t change what types of treatments are covered, but it does provide a direct option that avoids a hospital stay.

For more information about the waiver and whether your loved one’s condition could qualify, we recommend talking to your doctor and asking about the 1135 waiver.

1 Rachel M. Werner et al., “Patient Outcomes After Hospital Discharge to Home with Home Health Care vs to a Skilled Nursing Facility” JAMA Internal Medicine, March 11, 2019, https://ldi.upenn.edu/brief/patient-outcomes-after-hospital-discharge-home-home-health-care-vs-skilled-nursing-facility

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