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Does Medicare Cover Inpatient Rehabilitation?

Inpatient rehabilitation, sometimes called IRF, acute care rehab, or rehab, is a hospital that provides intensive therapies under a medical doctor's supervision. People may need an inpatient rehab admission after surgery, illness, or injury. Medicare covers inpatient rehabilitation services under Medicare Part A if certain conditions are met. This article discusses what Medicare covers during a rehab admission, what guidelines rehabs must follow, what qualifies a person for rehab, and how to rate quality care at a rehab facility.

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What does Medicare rehab cover?

If medically necessary, Medicare Part A will cover treatment at an inpatient rehabilitation facility or hospital. A person who has undergone surgery or is recovering from an illness or injury may qualify for rehab. Typical therapies offered at a Medicare-certified rehab facility include speech, occupational, and physical therapy. The specifics of these therapies and the treated conditions, like knee fractures or hip repair surgeries, are discussed in detail with a medical doctor, who supervises the therapy treatments. These treatments occur at least three hours a day, five times a week.

Nurses provide around-the-clock care for patients during their stay. Medicare will also cover a semi-private room, meals, prescription drugs, and other hospital services.

Medicare will not pay for a private room (unless medically necessary), private duty nursing, or personal items like toothpaste or razors (unless those things are included as part of your hospital admission).

Typically, the doctors’ services are charged separately from the rehab facility. If so, Medicare Part B will cover the doctors’ services during the inpatient rehab stay.

Medicare guidelines for inpatient rehabilitation facilities

To qualify for a Medicare-covered stay, a medical doctor must certify that the individual requires intensive therapy that a doctor must supervise.

To receive care reimbursement from the Center for Medicare and Medicaid Services (CMS), the rehab facility must follow the 60% rule. This rule states that 60% of a rehab’s patient population must be diagnosed with at least one of 13 conditions: stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, fracture of the hip, brain injury, burns, polyarthritis, systemic vasculitis with joint involvement, specified neurologic conditions, severe or advanced osteoarthritis, or knee or hip replacement.

If one of the above conditions is met, the patients must be offered three hours of therapy a day for at least five days a week during a seven-day week. If the patient is too debilitated to endure three hours of daily therapy, then the patient may attend 15 hours of therapy in seven days. Medicare requires daily documentation to support the need for therapy services. If documentation requirements are not met, Medicare can deny the rehab claim.

Medicare guidelines also require a rehab facility to provide a weekly physician-led interdisciplinary conference where the patient’s progress is discussed. The physician must visit the patient at least three times a week. Each patient must be provided with a case manager or social worker, and nursing services must be available 24/7.

How does Medicare payment for rehab work?

Medicare will cover an individual’s cost of an inpatient rehab stay if certain conditions are met, as described above. However, individuals are responsible for cost-sharing.

The number of days admitted to a healthcare facility dictates the payment amount. This is known as the benefit period.

Medicare.gov outlines the costs of a benefit period:

  • Days 1–60: $1,632 deductible
  • Days 61–90: a $408 copayment each day
  • Days 91 and beyond: an $816 copayment per each “after day 90 (up to a maximum of 60 reserve days over your lifetime) lifetime reserve day"
  • Each day after the lifetime reserve days: all costs
  • The benefit period ends when you haven't received any inpatient hospital care (or up to 100 days of skilled care in an SNF) for 60 consecutive days. If you go into a hospital or an SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period.

Because benefit periods occur in periods of 60 days, if you were previously admitted to a healthcare facility up to 60 days before your inpatient rehab admission, you will not have to pay a deductible because the previous 60-day admission deductible will count toward your inpatient rehab day. For example, if you were transferred from a hospital to a rehab facility, your hospital deductible will be applied to your rehab stay.

What conditions qualify for inpatient rehab?

A medical doctor will certify if you are a good fit for an inpatient rehabilitation stay. You must be able to complete at least three hours of therapy five times a week. A doctor will supervise the therapy treatment plans and your progress.

Some conditions that may qualify for an inpatient rehab stay include:

  • Brain illness (non-traumatic)
  • Brain injury (traumatic)
  • Cardiac conditions
  • Orthopedic injury or surgery like hip/knee fracture or amputation
  • Spinal cord injury or disease
  • Neurological issues like a stroke

Some rehabs have specialized programs and accreditations to treat these conditions. For example, the Joint Commission, a healthcare regulatory organization, issues accreditation for Disease-Specific Care in conditions like Parkinson's, heart failure, stroke, and hip fractures. When selecting a rehab, it is important to ensure that it is equipped to treat your specific condition.

How to select a good rehabilitation hospital

Medicare evaluates the quality of care provided by rehab hospitals. These quality rankings are available to the public online at Care Compare. You can enter your location information on the website to select up to three rehab hospitals to compare simultaneously. You’ll receive information such as what conditions they treat and scores related to results of care, improving functional capabilities, medication reconciliation completion, and infection rates.

If you need intensive therapy at a rehabilitation facility after a serious surgery or illness, Medicare can help cover the cost.

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