Medicare Coverage of Care in a Rehabilitation Hospital
If you qualify for Medicare-covered care in a rehabilitation hospital, your out-of-pocket costs will be the same as for any other hospital stay. If you enter a rehabilitation hospital after being an inpatient at a different hospital, you will still be in the same benefit period. A benefit period begins the day you start getting inpatient care and ends when you’ve been out of the Rehab hospital for 60 days in a row.
Rehabilitation hospitals are specialty hospitals (or parts of acute care hospitals) that offer intensive inpatient rehabilitation therapy.
You may need inpatient care in a rehabilitation hospital if you are recovering from a serious illness, surgery or injury and require a high level of specialized care from a team or medical professionals that generally cannot be provided in another setting (such as in your home or a skilled nursing facility).
Examples of common conditions that may qualify you for care in a rehabilitation hospital include stroke, spinal cord injury or brain injury. You will be less likely to qualify for care in a rehabilitation hospital if you are recovering from hip or knee replacement and have no other complicating condition.
If you do not qualify for Medicare-covered care in an inpatient rehabilitation hospital, you may qualify for rehabilitation care from other types of providers, such as a skilled nursing facility, a home health agency or in an outpatient setting.
Medicare-covered services offered by rehabilitation hospitals include:
- Medical care and rehabilitation nursing
- Physical, occupational or speech therapy
- Social worker assistance
- Psychological services
- Orthotic and prosthetic services
To qualify for Medicare-covered care in a rehabilitation hospital, your physician must certify that you need this type of intensive rehabilitation (this care must be documented as medically necessary).
For it to be considered medically necessary, it is required that all of the following services are needed to ensure safe and effective treatment:
- 24-hour access to a physician (meaning you require frequent, direct physician involvement, at least every 2-3 days)
- 24-hour access to a registered nurse with specialized training or experience in rehabilitation
- intensive therapy, which generally means at least three hours of therapy per day (but exceptions can be made on a case by case basis - you may still qualify if you are not healthy enough to withstand three hours of therapy per day).
- A coordinated team of providers including, at minimum, a physician, a rehabilitation nurse and one therapist.
- Your condition must be expected to improve enough from a stay in a rehabilitation hospital to allow you to function more independently. For example, therapy may help you regain the ability to perform “activities of daily living” on your own (such as eating, bathing and dressing) or live at home or with family rather than in a living facility.
After you pay a deductible each benefit period, Original Medicare will cover you in full for days 1 to 60 that you are in a hospital. For days 61-90, you pay a daily coinsurance. Medicare pays for up to 60 additional hospital days in your lifetime with a high daily coinsurance, after you have used up your 90 days of hospital coverage in a benefit period.
After you use up your 60 lifetime reserve days, Medicare will no longer pay for any coverage until you start a new benefit period.
A benefit period begins when you enter a hospital or a skilled nursing facility, and ends when you have been out of the hospital or skilled nursing facility (SNF), or stop receiving Medicare-covered skilled services at the SNF, for at least 60 days in a row.
If you buy any Medicare supplemental insurance policy (Medigap plans A-L) it will pay all your hospital coinsurance plus provide up to 365 additional lifetime reserve days. Plans B-J also pays your full hospital deductible.