Medicare Rehabilitation Rules: Everything You Need to Know

Many individuals with Medicare may wonder about the specifics of Medicare rehabilitation and its eligibility criteria. This article aims to demystify these rules, providing clarity on the prerequisites and conditions for receiving Medicare-funded rehabilitation.

Eligibility for Medicare Rehabilitation

To be eligible for rehabilitation under Medicare, a number of specific conditions must be met. First and foremost, a person must have been admitted to a hospital for at least three days and be identified as needing either skilled nursing care or rehabilitation services, such as physical, occupational, or speech therapy. This determination can be made upon admission to a rehabilitation center or nursing home.

Notably, Medicare typically separates short-term patients from long-term residents. While not always required, facilities generally maintain this separation to ensure that patients have appropriate care. If a patient requires therapy, they will undergo an initial evaluation once admitted to the rehabilitation center.

Initial Evaluation and Coverage Criteria

The first 20 days of a patient's stay are fully covered by Medicare, provided that the patient has not been in a rehab facility during the same year. During this period, the patient's progress must also be closely monitored. The therapists involved will collaborate with the patient and, if applicable, the patient's family to establish goals for recovery and safe discharge.

For instance, therapists may discuss the patient's previous level of activity and the goals necessary for safe discharge. Progress towards these goals is a critical factor in maintaining Medicare coverage. If a patient is not making sufficient progress, their Medicare coverage for the rehabilitation stay may be discontinued.

It is important to note that these rules apply to traditional Medicare recipients. Those enrolled in an HMO of Medicare may have different coverage rules, as these plans often have more rigid criteria set by the insurance company for coverage and discharge.

Medicare Coverage Eligibility for Post-Surgery Rehabilitation

For individuals undergoing surgery, Medicare typically covers 100% of the charges for the first 21 days of rehabilitation, provided the stay is medically necessary. Beyond these initial days, Medicare will cover 80% of the charges, with secondary insurance covering the remaining 20%. In all cases, the continued need for the patient's stay must be supported by the facility and physical therapy staff.

Throughout the rehabilitation process, there must be ongoing progress evaluations and justifications for the ongoing need for the patient to remain in the facility. This includes ensuring that the patient can safely function at home and that arrangements are in place for their transition back to home care.

Therapists are required to continuously justify the patient's progress and the safety of the patient's discharge. Any suspicion that the patient is not making progress or is malingering can result in the patient being discharged immediately.

Conclusion

Understanding Medicare's rehabilitation rules can be crucial for patients and their families. By adhering to the outlined requirements, patients can ensure they receive the necessary care under Medicare. For additional information or to discuss specific circumstances, it is advisable to consult with a healthcare provider or a Medicare representative.

Keywords: Medicare rehabilitation, Medicare rules, Medicare post-surgery rehab