Yes, Medicare does cover rehab if you have a medical condition that calls for it. Medicare Part A is responsible for rehab coverage.
You may need inpatient rehabilitation if you recently had a major surgery or a serious illness or injury. An intensive rehab therapy program involves supervision and coordinated care by doctors and therapists. Your doctor must certify that you need intensive rehab in a skilled nursing facility or an inpatient facility — also called an acute care rehab center or a rehabilitation hospital — to receive coverage from Medicare.
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Understanding Medical and Post-Surgical Rehab
Rehabilitation after surgery can expedite your recovery and even make your surgery and treatment more effective. Common treatments in medical rehab include:
- Physical therapy: Rebuilds your mobility and strength through exercises and stretches
- Occupational therapy: Helps you adapt to daily tasks like housework, caretaking, and walking through modifications
- Speech therapy: Treats any impaired ability to speak or swallow
- Pulmonary rehabilitation: Recovers breathing and lung function through breathing techniques and exercises to help raise your oxygen levels and build your endurance
Medical and post-surgical rehabilitation is critical to a successful recovery, especially in older adults. The therapies involved in post-surgical rehab help you rebuild strength while also resting and healing, ultimately improving the chances of your surgery’s long-term effectiveness.
Suppose you undergo rehab in an inpatient facility after surgery, an injury, or an illness. In that case, Medicare Part A can cover most of the cost, making this vital treatment more accessible.
How Does Medicare Coverage of Rehab Work?
Medicare Part A provides hospital insurance and covers medically necessary treatments, services, and equipment at inpatient rehabilitation centers. However, you must meet strict eligibility requirements to receive Medicare rehab coverage, and not all services are considered medically necessary.
Eligibility Requirements
To qualify for Medicare inpatient rehab coverage, your doctor must order your admission to the hospital and certify that your medical condition calls for intensive rehabilitation, including:
- 24-hour supervision by a medical doctor
- Frequent doctor interaction
- Access to a registered nurse who specializes in rehab services
- Therapy for at least three hours daily, five days each week (in most cases)
- Multidisciplinary care from a team of therapists and doctors
Moreover, Medicare will only cover rehab at a skilled nursing facility if you were first admitted to the hospital as an inpatient for at least three days. Otherwise, you might have to settle for outpatient rehab coverage.
Coverage
While you’re in inpatient rehab, Medicare will cover the following services and amenities:
- Semi-private room: If only a private room is available, Medicare will cover it until a semi-private room opens up.
- Meals: Your meals while in inpatient rehab will be covered. Original Medicare does not, however, pay for meal delivery services.
- Physical therapy: A physical therapist assesses and treats conditions affecting your physical ability and function. Physical therapy improves, maintains, or slows the progression of your condition.
- Occupational therapy: If your condition impacts your daily living abilities, which may include climbing stairs, getting dressed, or taking baths, occupational therapy can help. It can slow your decline or help you maintain or improve your current abilities.
- Speech-language pathology: Colloquially known as speech therapy, this service rebuilds your speech, language, and swallowing skills.
- Social services: Medical social services, such as the evaluation of your emotional and social state as it relates to your treatment, make meaningful contributions to the treatment of your condition.
- Nursing services: These may include assistance with daily living, mobility exercises, hygiene, nutrition, and housekeeping, depending on your needs.
- Prescription drugs: Medicare pays for your prescriptions as part of a covered inpatient rehabilitation stay.
- Other hospital services and supplies: Medicare covers supplies, appliances, equipment, and services provided by the facility as part of the inpatient rehabilitation stay.
Covered Rehab Facilities
Medicare covers intensive inpatient rehabilitation in several types of facilities, including those listed below. Note that the terms of Medicare rehab coverage specified below apply to each benefit period.
Facility Type | Coverage Timeframe |
|---|---|
Skilled Nursing Facilities | For up to 100 days following a procedure or an injury, such as a hip replacement |
Inpatient Rehab Facilities | After a serious medical incident, fully covered for up to 60 days, $400 daily copay for days 61 to 90, $800 daily copay for every lifetime reserve day after day 90 |
Acute Care Rehab Centers | After a serious medical incident, fully covered for up to 60 days, $400 daily copay for days 61 to 90, $800 daily copay for every lifetime reserve day after day 90 |
Rehab Hospitals | After a serious medical incident, fully covered for up to 60 days, $400 daily copay for days 61 to 90, $800 daily copay for every lifetime reserve day after day 90 |
Coverage Limitations
Medicare only covers services and equipment deemed medically necessary by your doctor. In most cases, the following are not covered:
- A private nurse: Private-duty nursing is not covered under Medicare Part A.
- Personal items: Medicare does not cover personal necessities such as toiletries and clothes.
- A phone or TV: If your facility assesses an additional charge for these items in your room, Medicare will not cover those expenses.
- A private room, unless medically necessary: Medicare only covers semi-private rooms and wards.
Rehab Coverage With Medigap
Original Medicare does not cover 100% of the costs associated with inpatient rehab, leaving beneficiaries to foot the bill for deductibles, copays, and coinsurance, among other expenses. That’s where Medigap can help. If you have a standard Medigap policy, it should help pay for some of the rehab expenses that Original Medicare does not cover.
Rehab Coverage With Medicare Advantage
Medicare Advantage plans must include all of the benefits provided by Original Medicare, so you can count on your Medicare Advantage policy to help pay for medically necessary inpatient rehabilitation.
However, since Medicare Advantage plans come from private insurers, your policy’s coverage guidelines and your out-of-pocket costs may vary based on your provider and plan. You might even get some additional benefits on top of the coverage provided by Medicare Part A.
If you have a chronic or severe condition and you anticipate needing long-term or consistent rehabilitation, you might consider a Medicare Advantage Special Needs Plan. These plans extend the coverage provided by Original Medicare; for example, they might pay for extra time in the hospital if you have a condition that warrants it.
How Much Does Rehab Cost?
The exact cost of acute rehab care varies depending on your location, the length of your stay, the nature of your recovery, and the type of facility providing your care. Without insurance, you could pay around $1,500 per day for post-surgical rehab. Here’s what your out-of-pocket costs might look like with Original Medicare coverage:
Out-of-pocket costs | |
|---|---|
Days 1 – 60 | $1,600 deductible |
Days 61 – 90 | $400 daily copay |
Days 91 and beyond | $800 copay per lifetime reserve day (after 90 days in a hospital, you tap into your Medicare-covered lifetime reserve days, of which you only have 60 total) |
Every day after exhausting your lifetime reserve days | All costs |
If you transfer directly from an acute care hospital to an inpatient rehab facility or you check into an inpatient rehab facility within 60 days of your hospital discharge, you will not have to pay a deductible for acute care rehab.
If you have a Medicare Advantage plan, your coverage should at least match that provided by Medicare Part A. Some types of Medicare Advantage plans cover additional time in inpatient rehab. However, coverage guidelines for Medicare Advantage plans vary by provider and policy.
How to Get Rehab Covered by Medicare
- Enroll in Medicare parts A and B. These parts make up Original Medicare. Enroll during your initial enrollment period, which starts three months before your 65th birthday month and ends three months after your 65th birthday month.
- Obtain doctor certification. If you need inpatient rehab following an injury, an illness, or surgery, ensure your doctor certifies rehabilitation as medically necessary. Your doctor must verify that you need intensive rehabilitation, ongoing supervision by a medical team, and coordinated medical care due to your condition.
- Ensure your claim is filed. You should not have to file a claim for covered treatments as long as you have Original Medicare. Your medical provider is required by law to file the claim for you.
Outpatient Therapy with Medicare
In addition to inpatient rehab, Medicare covers medically necessary outpatient rehabilitation services such as physical therapy, occupational therapy, and speech-language pathology therapy. Like inpatient services, your healthcare provider must certify that outpatient rehab services are necessary for Medicare to cover them.
For each of the above-mentioned outpatient therapy services, Original Medicare covers 80% of the Medicare-approved amount after you’ve met your Part B deductible. If you have a Medicare Advantage plan, you may receive additional coverage.
There is no limit on Medicare’s annual coverage of medically necessary outpatient rehab services. However, if your therapist recommends more frequent treatment than or outside of what your Medicare plan will cover, you may have to pay for those treatments out of pocket.
Long-Term Rehabilitation with Medicare
Depending on the nature of your condition or recovery, you may benefit from long-term inpatient rehabilitation. However, with the exception of your lifetime reserve days, Medicare does not cover inpatient acute care for longer than 90 days. Medicare Advantage plans may provide additional coverage, but details vary from plan to plan.
Generally speaking, once you’ve exceeded a 90-day inpatient stay and exhausted your lifetime reserve days, you are responsible for 100% of your long-term care costs, which are not cheap. For example, the median monthly cost of a semi-private room in a nursing home facility exceeds $7,900.
Medicaid does provide long-term care coverage to eligible beneficiaries. If you do not qualify for Medicaid, you can purchase long-term care insurance.
Putting it Together
If you’re recovering from a severe injury or illness or a major surgery, you may require around-the-clock medical care in an inpatient rehabilitation facility. Medicare covers medically necessary inpatient care, allowing you to access the therapies you need to recover and return to your daily life.
Medicare only covers inpatient care for up to 90 days, however, so if you require long-term custodial care, you may need to seek other coverage options from Medicaid or private insurers.