When Does Medicare Cover Rehabilitation?

When you or your elderly loved one needs short-term rehabilitation after an illness or injury, you may assume Medicare will cover the stay. Rehabilitation falls squarely in the “medically reasonable and necessary” category, so you’d be justified in that assumption.

Unfortunately, that’s not quite how it works. You need to have a “qualifying hospital stay” in order for Medicare coverage to kick in for the rehab. While many, if not most, pre-rehabilitation hospital stays do qualify, some don’t. In this article, we’ll explain what a qualifying hospital stay is, and how you can find out if your stay qualifies.

Skilled Nursing Care Coverage

Skilled nursing care is care that can only be administered by doctors or nurses. This can include IV injections, certain treatments, and all therapies. Rehabilitation is considered skilled nursing care, and is supposed to be short-term. Long-term care is usually custodial—the resident needs to live in a safe, supervised environment but does not need specialized care.

Part A Medicare covers care in a skilled nursing facility (SNF) as long as you meet the following conditions:

• You have days remaining in your Part A benefit period.
• You have a qualifying hospital stay.
• Your doctor has prescribed daily skilled care given by, or under the direct supervision of, skilled nursing or therapy staff. (If you’re in a SNF for rehab only, your care is considered daily care even if these therapy services are offered just 5 or 6 days a week, as long as you need and get the therapy services each day they’re offered.)
• You get these skilled services in a Medicare-certified SNF.
• You need these skilled services for a hospital-related medical condition.

Today we’ll focus on the qualifying hospital stay.

A qualifying hospital stay is when you’ve been an inpatient at the hospital for at least 3 days. Just because you’ve stayed at the hospital overnight in a hospital bed in a regular room, it does not mean you’ve been admitted. Your doctor may have decided to keep you at the hospital for “observation” until he determines if you need to be admitted or can be discharged. If you were never formally admitted, or you only spent two days as an official inpatient, there was no qualifying stay.

According to Medicare, the last inpatient day is the day before discharge. So if you’re discharged on the third day of your inpatient stay, you also forfeit your qualifying stay.

Before leaving the hospital for skilled nursing and rehab, make sure you had a 3-day qualifying stay. If your official inpatient stay did not cross the threshold of 3 full days, your rehabilitation will not be covered by Medicare.

As a side note, Medicaid does cover rehabilitation at a skilled nursing facility, regardless of how long you were in the hospital. Because Medicaid is a safety net program, your eligibility is determined by income level. If Medicare will not cover your rehab and you’d like to get onto Medicaid, please contact us for more information.