- Original Medicare (Part A and Part B) will pay for inpatient rehabilitation if it’s medically necessary following an illness, injury, or surgery once you’ve met certain criteria.
- In some situations, Medicare requires a 3-day hospital stay before covering rehabilitation.
- Medicare Advantage plans also cover inpatient rehabilitation, but the coverage guidelines and costs vary by plan.
Recovery from some injuries, illnesses, and surgeries can require a period of closely supervised rehabilitation. Medicare covers your treatment in an inpatient rehabilitation facility as long as you meet certain guidelines.
The guidelines discussed in this article relate to inpatient medical or postsurgical rehabilitation — not inpatient rehabilitation for a substance use disorder. You can learn more about Medicare’s guidelines for treatment of substance use disorders here.
Medicare Part A covers your inpatient care in a rehabilitation facility as long as your doctor deems it medically necessary. In addition, you must receive care in a facility that’s Medicare-approved.
Depending on where you receive your inpatient rehab therapy, you may need to have a qualifying 3-day hospital stay before your rehab admission. We’ll discuss that rule in more detail later.
If you’re enrolled in original Medicare (Medicare Part A and Part B) in 2020, you’ll pay the following costs during each benefit period:
- Days 1 through 60. You’ll be responsible for a $1,364 deductible. If you transfer to the rehab facility immediately after your hospital stay and meet your deductible there, you won’t have to pay a second deductible because you’ll still be in a single benefit period. The same is true if you’re admitted to a rehab facility within 60 days of your hospital stay.
- Days 61 through 90. During this period, you’ll owe a daily coinsurance amount of $341.
- Day 91 and onward. You’ll pay $682 coinsurance for each of your lifetime reserve days. You have 60 lifetime reserve days. After you’ve used them all, you’re responsible for all costs.
What is a benefit period?
Each benefit period begins the day you’re admitted to a hospital or skilled nursing facility as an inpatient. The period ends 60 consecutive days after your stay without further inpatient care.
If you need to return to the hospital and are admitted within 60 days of your previous stay, you’ll still be in that benefit period. However, if you go back to the hospital after the 60 days without care, a new benefit period begins.
Costs with Medicare Advantage
If you have a Medicare Advantage (Part C) plan, your costs will vary based on your insurer. Talk with your plan advisor or insurance company in advance, if possible, so you can prepare for any out-of-pocket costs.
If you think you may need long-term care, you can explore the available Medicare Advantage Special Needs Plans. These plans are designed to offer extra benefits for people with chronic health conditions, as well as people enrolled in both Medicare and Medicaid.
Costs with Medigap
Adding Medigap (Medicare supplement) coverage could help you pay your coinsurance and deductible costs. Some Medigap plans also offer additional lifetime reserve days (up to 365 extra days).
You can search for plans in your area and compare coverage using Medicare’s plan finder tool.
During inpatient rehabilitation, a team of healthcare professionals will work together to help you function on your own again. Your treatment plan will be tailored to your condition but may include:
- assistance with orthotic or prosthetic devices
- occupational therapy
- physical therapy
- psychological services
- social services
Rehabilitation may take place in a special section of the hospital, in a skilled nursing facility, or in a separate rehabilitation facility.
Although Medicare covers your care during rehabilitation, it’s not intended to be long-term care. You can learn more about Medicare and long-term care facilities here.
To ensure Medicare will cover your inpatient rehabilitation, follow the basic guidelines outlined below.
Make sure you’re enrolled in Medicare
You can first enroll during a 7-month window called the initial enrollment period. This period starts 3 months before you turn 65 years old and ends 3 months after your birth month.
Another opportunity to enroll is during Medicare’s open enrollment period, which is from October 15 to December 7 each year.
If you’re considering a Medicare Advantage (Part C) plan, your enrollment period runs from January 1 through March 31 each year. Depending on your situation, you may also qualify for a special enrollment period.
Confirm your initial hospital stay meets the 3-day rule
Medicare covers inpatient rehabilitation care in a skilled nursing facility only after a 3-day inpatient stay at a Medicare-approved hospital.
It’s important that your doctor write an order admitting you to the hospital. If you’ve spent the night in the hospital for observation or testing, that won’t count toward the 3-day requirement.
These 3 days must be consecutive, and any time you spent in the emergency room before your admission isn’t included in the total number of days. Your discharge day is also not included in the 3-day total.
It can be hard to know if you’ve been admitted as an inpatient or how long your stay has been. This might leave you unsure whether you qualify for the 3-day rule. This is a helpful guide for determining your inpatient status. You can use this guide when talking with your doctor to get the information you need.
If you’re having surgery, check Medicare’s 2020 “inpatient only” list
Some surgical procedures always require admission as an inpatient. The 3-day rule does not apply for these procedures, and Medicare will cover your inpatient rehabilitation after the surgery. These procedures can be found on Medicare’s inpatient only list.
In 2018, Medicare removed total knee replacements from the inpatient only list. In 2020, Medicare also removed total hip replacements from the list. The 3-day rule now applies to both of those procedures.
If you have a Medicare Advantage plan, talk with your insurance provider to find out if your surgery is considered an inpatient-only procedure. Each plan’s coverage rules differ, and knowing whether the 3-day rule applies could save you a lot of money.
If you have a Medicare Advantage (Part C) plan, your costs may be higher or lower based on whether your healthcare providers and rehab facility are in network or out of network. Check with your plan before being admitted to a facility to make sure that it’s in network. This will help ensure full coverage and maximum cost savings.
Verify that your doctor’s order includes the required information
To ensure Medicare coverage for your inpatient rehabilitation, your doctor will have to certify that you need:
- access to a medical doctor 24 hours per day
- frequent interaction with a doctor during your recovery
- access to a registered nurse with a specialty in rehabilitation services
- therapy for at least 3 hours per day, 5 days per week (although there is some flexibility here)
- a multidisciplinary team to care for you, including a doctor, rehabilitation nurse, and at least one therapist
When in doubt, talk with your doctor or call Medicare
Though you don’t always have advance notice with a sudden illness or injury, it’s always a good idea to talk with your healthcare team about Medicare coverage before a procedure or inpatient stay, if you can.
If you want to confirm you’re following Medicare procedures to the letter, you can contact Medicare directly at 800-MEDICARE (800-633-4227 or TTY: 877-486-2048).
Inpatient rehabilitation is goal driven and intense. You and your rehab team will create a coordinated plan for your care. The primary aim will be to help you recover and regain as much functionality as possible.
Your team will include registered nurses who specialize in rehab care, along with one or more physicians and rehab therapists, depending on your health condition. You might also receive assistance from psychologists, psychiatrists, or social workers who can help with your mental and emotional well-being.
You may work with a physical therapist to:
- rebuild your strength and ability to move
- increase your range of motion
- decrease pain and swelling
You may work with an occupational therapist to:
- learn how to use any medical devices you’ll need during recovery
- perform the activities of daily living during your recovery
- prepare for life at home after you’re discharged
You may work with a speech and language pathologist to:
- rebuild your vocabulary and practice word retrieval
- swallow food and drinks
- learn new ways to communicate
Inpatient rehabilitation is often necessary if you’ve experienced one of these injuries or conditions:
- brain injury
- heart attack
- orthopedic surgery
- spinal cord injury
Original Medicare and Medicare Advantage plans pay for inpatient rehabilitation if your doctor certifies that you need intensive, specialized care to help you recover from an illness, injury, or surgical procedure.
You might receive inpatient rehabilitative treatment in a dedicated rehab department inside a hospital, at a skilled nursing facility, or at a separate rehabilitation clinic or hospital.
You must meet certain important conditions in order for Medicare to cover your inpatient rehab. You’ll still have to pay for the cost of coinsurance and deductibles, even with Medicare coverage.
While you’re in rehab, your care will be provided by a team that’ll include nurses, doctors, and therapists. They can help you get back on your feet as quickly and as safely as possible.