Has your healthcare team suggested that a stay in a short term rehab facility would be the best next step in your care after hospital discharge? If so, you likely have questions about the financial aspects of getting the care you need, and those questions are best dealt with before your admission to prevent unpleasant surprises later. Here, we'll outline what you need to know in terms of insurance considerations for short term rehab.
Medical necessity: The basic requirement for coverage
While the exact details of coverage for short term rehab vary to some degree from one insurance plan to another, virtually all will require you to show medical necessity in order to have your rehab stay covered. According to the American Stroke Association, proving medical necessity means meeting one of the following standards:
Rehabilitation services are expected to prevent onset of an illness, condition or disability.
Services are expected to reduce the physical, mental or developmental effects of an illness, condition or disability.
Rehab will help a person achieve or maintain maximum functional capacity in daily activities.
Your medical team will be aware of these standards, and if they have offered a referral, chances are you'll meet them. That said, it is wise to ask just to double check.
If you are a Medicare recipient
Medicare will cover short term rehab under certain circumstances. To qualify for coverage, you must meet the following criteria:
A doctor or nurse practitioner must certify that you need skilled rehab services 5 days a week or skilled nursing care 7 days a week.
Your hospital stay must be at least 3 consecutive days, not counting discharge day, and your admission to rehab must be within 30 days of that hospital stay.
Your rehab stay must be for the same illness or injury treated during your hospital stay.
You must be assessed by rehab staff at least once a week to determine whether you have reached "restorative potential"—which basically means that your rehabilitation team has determined that you have reached rehabilitation goals set forth in your treatment plan.
Medicare will pay the full cost of short term rehab services for qualified beneficiaries during the first 20 days and will offer partial coverage for the next 80 days. If you have a Medigap policy, it may pay some or all of the costs incurred during that 80-day partial coverage period.
About Medicaid for short term rehab
Medicaid offers coverage for inpatient rehab services for income-qualified patients, provided that these services are deemed medically necessary. Some Medicare beneficiaries may qualify for assistance in covering charges not paid by Medicare after the initial 20 days of their rehab stay.
Most private insurance plans use the same general guidelines as Medicare to determine eligibility for short term rehab coverage. However, it is not wise to make assumptions about coverage, so be sure to get in touch with your insurance company at admission to rehab and periodically during your stay to ensure that all requirements for coverage are met.
For additional, individualized information
Understanding just what is covered and what isn't can be confusing, especially if you, like many people, are working with some combination of government and private insurance plans. For that reason, seeking help from someone with expertise in navigating insurance issues is the best way to ensure that you have your financial ducks in a row. Most hospitals offer the services of social workers and discharge planners in sorting out these issues, and rehab facilities you're considering for your care will have financial offices to assist patients in assessing insurance coverage.