Medicare Coverage of Inpatient Rehabilitation Stays
Medicare Part A will pay for most of the costs of your stay in an inpatient rehabilitation facility (IRF).
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Medicare Part A covers most of the cost of care when you stay at an inpatient rehabilitation facility (sometimes called a rehabilitation hospital). Your doctor may send you to an inpatient rehabilitation facility if you are recovering from major surgery such as bilateral hip replacement or a serious injury or illness such as a stroke or spinal cord injury and you require a team of medical professionals and intensive therapy to help you recover.
What Is an Inpatient Rehabilitation Facility?
An inpatient rehab facility (IRF) is sometimes called an acute care rehabilitation center. An IRF can be a separate wing of a hospital or can be a stand-alone rehabilitation hospital. IRFs provide intensive, multi-disciplinary physical or occupational therapy under the supervision of a doctor as well as full-time skilled nursing care.
Skilled nursing facilities sometimes call themselves post-acute rehabilitation centers, but they are not IRFs. The rules for a Medicare-covered stay in a skilled nursing facility are very different; see our article on Medicare coverage for skilled nursing facilities.
Who Qualifies for Medicare Coverage of a Stay in an Inpatient Rehabilitation Facility
For Medicare to pay for your stay in an intensive inpatient rehabilitation center, your doctor must certify that you need:
- intensive physical or occupational rehabilitation (at least three hours per day, five days per week)
- at least one additional type of therapy, such as speech therapy, occupational therapy, or prosthetics/orthotics
- full-time access to a doctor with training in rehabilitation, including at least three visits per week, and
- full-time access to a skilled rehabilitation nurse.
Medicare cannot deny coverage because your condition is not expected to improve enough to enable you to return home or to your prior level of functioning.
If you don't need intensive rehabilitation, but you do need full-time nursing care, Medicare Part A could cover a stay in a skilled nursing facility instead. Or, if you don't need intensive rehab and you only need part-time nursing care, Medicare could cover home health care visits. For more information, see our articles on Medicare coverage of skilled nursing facilities and Medicare coverage of home health care.
How Much Medicare Pays for an Inpatient Rehabilitation Stay
Medicare Part A reimburses stays at an inpatient rehabilitation facility in the same way as it reimburses regular hospital stays; in other words, you will have the same out-of-pocket costs. Accordingly, Medicare pays only certain amounts of your stay at an IRF. For the first 60 days you are an inpatient in an IRF, Part A hospital insurance pays for everything. After your 60th day in an IRF, and through your 90th day, you must pay a daily co-pay $296 (in 2013).
If you are in an IRF more than 90 days (during one spell of illness), you can use up to 60 additional "lifetime reserve" days of coverage. During those days, you are responsible for a daily coinsurance payment of $592 per day, in 2013, and Medicare will pay the rest. You have only 60 reserve days to be used over your whole lifetime, for both hospital and IRF stays combined.
When You Must Pay the Medicare Part A Deductible
There is no requirement that you first stay in a regular hospital for a certain number of days (as with Medicare coverage of skilled nursing facilities), but if you don't, you will need to pay the Part A deductible of $1,184 (in 2013).
If you are transferred from an acute care hospital, the deductible you pay for the hospital stay counts for the rehabilitation stay as well.
What Medicare Covers During an IRF Stay
When you are admitted to an IRF, Medicare Part A hospital insurance will cover the following for a certain amount of time:
- a semiprivate room
- all meals
- regular nursing services
- social worker services
- drugs, medical supplies, and appliances furnished by the facility, such as casts, splints, wheelchair, and
- rehabilitation services, such as physical therapy, occupational therapy, and speech pathology, provided while you are in the IRF.
What Medicare Does Not Cover During an IRF Stay
Medicare Part A hospital insurance does not cover:
- personal convenience items such as television, radio, or telephone
- private duty nurses, or
- a private room when not medically necessary.
What Constitutes an IRF vs. a Skilled Nursing Facility
Whether you are transferred to an IRF or a skilled nursing facility is an important distinction because Medicare covers a different number of days for an IRF than it does for skilled nursing, and you pay a different co-payment. In addition, Medicare compensates the facility differently. To be compensated by Medicare as an IRF, the facility must be approved by Medicare and at least 60% of cases an IRF admits have one or more of the following conditions:
- traumatic brain injury
- a neurological disorder such as Parkinson's, MS, or muscular dystrophy
- spinal cord injury
- major multiple traumas
- hip fracture
- knee or hip replacement for both legs, or when the patient's BMI is 50 or higher, or when the patient is age 85 or older
- congenital deformity, or
- arthritis that impairs one's ability to walk and take care of oneself and meets other criteria.