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Medicare Advisor—Coverage for rehabilitation following stroke

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Note to readers: This question was submitted by a non-therapist.

Question: How does Medicare coverage work for someone who needs rehabilitation after a stroke? In my mother's case, she went to a nursing home for rehabilitation. The rehab staff has recommended that she be transferred to an inpatient rehab facility for more intensive therapy because she is doing so well.

Answer: Medicare benefits are complex. You need to speak with a social worker or other knowledgeable person face to face to get a complete answer to your question. S(he) should be able to explain to your mother and you the benefits for which your mother is eligible. Below is a very brief answer to your question. It in no way should be interpreted to supercede any information from Medicare or any explanations from persons knowledgeable about your mother's case.

Medicare has two parts: Part A and Part B. Part A benefits are free to eligible Americans (and some legal resident aliens) at age 65 and some others with special qualifications. In order to have Part B benefits, you mother must pay a certain amount each month to the government. In addition, your mother may have purchased private Supplemental Medical Insurance, which covers deductibles and copays that Medicare does not cover.

Part A covers a qualifying stay in an acute care hospital while she stabilizes after her stroke, which is generally three to five days. In order to be eligible for Part A benefits for post-hospitalization rehabilitation in either an inpatient rehab facility (IRF), skilled nursing facility (SNF) or hospital based skilled nursing unit (SNU) after hospital discharge, your mother must meet certain requirements. These include a qualifying three-day hospital stay, admission to the facility within 30 days of hospital discharge, and treatment directed at the problem for which your mother was admitted to the hospital. In order to stay eligible to use the benefits, she must continue to need skilled nursing or rehabilitation for this same problem.

If she continues to meet the eligibility requirements, she may have up to a total of 100 days of Part A benefits in a SNF or SNU (even if she moves from one skilled nursing facility to another).  If so, the first 20 days are paid completely (including room, board and therapy) by Medicare.  Medicare covers 80 percent of the cost from day 21 to day 100. The other 20 percent comes out of your mother's pocket, or may be paid by supplemental medical insurance.

Just because Part A will pay for up to 100 days of rehab in a SNF/SNU doesn't mean your mother is guaranteed to be able to use the entire 100 days. At any time during the 100 days, if the facility and your mother's physician determine that your mother no longer qualifies for Part A skilled nursing or therapy, Medicare will no longer pay for the stay. This can happen at any time during the 100 days. If she uses all 100 days and still requires therapy, Medicare Part B (if she has paid for this) will cover 80 percent of the cost of therapy services, but not room and board.

An IRF stay is paid under Part A as part of the (up to) 90 days of acute care to which she is entitled. In order to qualify for IRF rehabilitation, your mother must be able to tolerate at least three hours of therapy a day. Your mother's case is unusual; normally patients using an IRF go directly from the acute hospital to the IRF.

  • If you have a question about Medicare reimbursement you would like the authors to address, send your question and contact information to Medicare Advisor, c/o Linda Jones, ADVANCE for PTs & PTAs, 2900 Horizon Dr., King of Prussia, PA 19406; fax (610) 278-1425; ljones@merion.com.

    Pauline Watts and Danna Mullins are the co-founders of and principal lecturers for Encompass Education Inc., a rehabilitation education and consulting firm in Palm Harbor, FL. Contact the authors at medicareadvisor@encompasseducation.com




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