Heart Attack, Stroke, and Medicare Coverage

Experiencing a heart attack is far more likely after age 65. Likewise, 75 percent of strokes occur after this age. For an employed senior, either a heart attack or stroke can signal the end of decades of employment due to subsequent permanent disability. As more adults are working longer in life, preparing in advance for a shift from employer-based health insurance to Medicare is crucial.

For anyone at heightened risk for heart attack, stroke, or major surgery, this includes understanding Medicare’s rehab services coverage. The following describes the health-related thresholds that need to be met for Medicare to cover your rehab services.

What is “Medical Necessity” and Why Does it Matter?

Whether you are enrolled in Original Medicare or a Medicare Advantage plan, your doctor’s determination of “medical necessity” is important to receiving Medicare coverage for rehab services. For “medical necessity” to be noted, your doctor must believe that that you will benefit by receiving such additional services. Therefore, your attitude toward undertaking a prescribed rehab regimen can affect your doctor’s decision (as a refusal to undertake physical therapy upon transfer to a rehab unit can result in a Medicare coverage denial).

If you need to prove “medical necessity” to receive coverage for a specific rehab service (such as your outpatient physical therapy total annual cost exceeding a specified dollar threshold), a Medicare form (CMS 1960, Request for Evidence of Medical Necessity) needs to be submitted by your doctor.

The Three-Day Rule and Medicare Coverage

A patient has to remain in the hospital for at least three consecutive days for Medicare to cover a stay in a Skilled Nursing Facility (SNF), per the Center for Medicare Advocacy. However, someone walking into a hospital ER with chest pain may be placed on “observation status” in that hospital – rather than admitted – prior to receiving the actual heart attack diagnosis.

This is one common way that a Medicare beneficiary with a heart attack diagnosis can be transferred to a SNF at less than a documented three-day hospitalization (and then receive an astronomical SNF bill after discharge).

Why Physical Therapy is Important after a Stroke or Heart Attack

Stroke is one of the leading causes of disability in the US (according to the National Stroke Association). Even a mild stroke can impact balance or gait, and falling is the leading cause of fractures in people aged 65 and older.

For a senior living with a disabled spouse or alone, transfer to a SNF can be a safer alternative than immediate discharge home (and rehab therapy often begins within 48 hours of a stroke). Meanwhile, rehab after a heart attack usually includes a daily exercise regimen.

Medicare Advantage and Rehab Services

While Medicare Advantage plans may cover more rehab services costs than Original Medicare, you need to understand your Medicare Advantage plan’s coverage. According to an article in 2018 in the New York Times, 33 percent of Medicare beneficiaries in 2017 opted for a Medicare Advantage plan (as compared to 16 percent in 2006).

In order to assess whether Original Medicare or a Medicare Advantage plan will better suit your needs, it is vital to consider your overall health status and health risk factors (as well as your financial resources). Consulting with an agent at UrHealth Benefits can aid you in enrolling in the Medicare coverage that is best for your healthcare needs.

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