If you sometimes feel stumped by the nuances of health insurance, don’t feel bad. A recent study showed that 96% of Americans overestimate their understanding of the subject.

Thankfully, not all health insurance is created equal or equally complicated. The nation’s largest health insurance program, Medicare, covers people over the age of 65, or those under 65 who have been totally and permanently disabled for at least 10 years. 

Your Guide to Medicare and Rehabilitation Services 600

Medicare has straightforward terms about the intensive inpatient rehabilitation services it covers in a specialty hospital or unit within a hospital. The good news is that hospital rehabilitation care may be available at little or no cost to you.

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 that generally cannot be provided in another setting (such as in your home or a skilled nursing facility). These conditions could include: stroke or injury of your spinal cord or brain.

What kind of inpatient rehab does Medicare cover?

Medicare pays for rehabilitation deemed reasonable and necessary for treatment of your diagnosis or condition. Medicare will pay for inpatient rehab for up to 100 days in each benefit period, as long as you have been in a hospital for at least three days prior. A benefit period starts when you go into the hospital and ends when you have not received any hospital care or skilled nursing care for 60 days.

Medicare-covered services offered by rehabilitation hospitals include:

  • Medical care and rehabilitation nursing
  • Physical, occupational and speech therapy
  • Social worker assistance
  • Psychological services
  • Orthotic and prosthetic services

Keep in mind that if you do not qualify for a Medicare-covered stay in an inpatient rehabilitation hospital, you may qualify for rehabilitation care from a skilled nursing facility, a home health agency or in an outpatient setting.

What is required for coverage?

For Medicare to cover your stay in a rehabilitation hospital, your doctor must determine that this care is medically necessary, and you meet the following conditions to ensure safe and effective treatment:

  • You need 24-hour access to a doctor, and see one at least every two to three days
  • You need 24-hour access to a Registered Nurse who has specialized training or experience in rehabilitation
  • Your condition requires intensive therapy, which generally means at least three hours of therapy per day (but you may still be able to get inpatient rehab if you are not yet healthy enough for this length of daily rehab)
  • You need a coordinated team of providers including, at minimum, a doctor, a rehabilitation nurse and one therapist

Your doctor must also expect that you will improve enough to live more independently after inpatient rehab. For example, therapy may help you be able to complete daily activities like eating, bathing and dressing on your own, so you can transition to a lower level of care like assisted living or skilled nursing, or at home.

What doesn’t Medicare cover?

If you don’t meet the requirements above, it may be because your condition doesn’t create a need for the intense level of care and rehab in this setting. As an example, if you are recovering from hip or knee replacement and have no other complicating condition, you could receive care in a skilled nursing facility, outpatient rehab or rehab at home.

What would I need to pay?

If Medicare will cover your care in a rehabilitation hospital, your out-of-pocket costs will be the same as for any other inpatient hospital stay. Medicare pays for the first 20 days at 100 percent. For the next 80 days, you must pay a daily co-payment. Medicare does not pay for rehabilitation services after 100 days.

For more information, call Medicare toll-free at 1.800.638.6833.

If you have questions about hospital rehabilitation services, call 1.866.KINDRED to speak with a Registered Nurse 24 hours a day, seven days a week. Our nurses can help determine if this type of care is right for you or your loved one, and if your health plan covers it.

By Mike Ogburn