Inpatient Rehabilitation Facility
To qualify for a Medicare-covered stay in a rehabilitation hospital, you, as the clinician, must state that the care is medically necessary. Meaning, your patient must require all the following services for their stay to be covered:
- 24-hour access to a doctor (meaning you require frequent, direct doctor involvement, at least every 2-3 days),
- 24-hour access to a registered nurse with specialized training or experience in rehabilitation,
- intensive therapy, which generally means at least three hours of therapy per day (but exceptions can be made on a case by case basis—you may still qualify if you are not healthy enough to withstand three hours of therapy per day), and
- the “three-hour rule,” issue of 15 hours of therapy (physical, occupational, speech language, and orthotic or prosthetic) over 7 days, which typically breaks down to three hours per day.
- a coordinated team of providers including, at minimum, a doctor, a rehabilitation nurse, and one therapist.
You must also expect that the rehabilitation stay will improve the patient’s condition enough to allow him or her to function independently as a result of the stay.[i]
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Skilled Nursing Facility:
Patients with Medicare are covered if they meet the following conditions:
- You have Part A and have days left in your benefit period;
- you have a qualifying hospital stay (3 midnights);
- your doctor has decided that you need daily skilled care given by, or under the direct supervision of, skilled nursing or therapy staff. If you're in the SNF for skilled rehabilitation services 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 SNF that's certified by Medicare; and
- you need these skilled services for a medical condition that was either:
- a hospital-related medical condition, or
- a condition that started while you were getting care in the skilled nursing facility for a hospital-related medical condition.
You may also order observation services to help decide whether your patient needs to be admitted to the hospital as an inpatient or can be discharged. During observation services, the patient is considered an outpatient—it does not count towards the 3-midnight inpatient hospital stay needed for Medicare to cover the SNF stay.[ii]
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Long Term Acute Care Hospital:
Under Medicare, the patient must need more than 25 days of hospitalization to be eligible for an LTCH.[iii],[iv] The average length of stay of a person in an LTCH is approximately 27.3 as of 2015.[v]
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Services covered by Medicare’s home health benefit include intermittent skilled nursing care, therapy (physical, occupational, and speech language),[vi] and care provided by a home health aide. Depending on the circumstances, home health care will be covered by either Part A or Part B. Medicare covers home health care if the patient is under a doctor’s care and the doctor certifies that the patient is/needs at least one of the following:
- Patient is homebound, meaning it is extremely difficult for the patient to leave his or her home and needs help doing so.
- Patient needs skilled nursing services and/or skilled therapy care (physical, speech, and occupational therapy) on an intermittent basis
- Intermittent means the patient need care at least once every 60 days and at most once a day for up to three weeks. This period can be longer if he or she need more care, but care needs must be predictable and finite.
- Medicare defines skilled care as care that must be performed by a skilled professional, or under their supervision.
- Patient has a face-to-face meeting with a doctor within the 90 days before you start home health care, or the 30 days after the first day you receive care. This can be an office visit, hospital visit, or in certain circumstances a face-to-face visit facilitated by technology (such as video conferencing).
- Doctor signs a home health certification confirming that you are homebound and need intermittent skilled care. The certification must also state that your doctor has approved a plan of care for you and that the face-to-face meeting requirement was met.
- A doctor should review and certify your home health plan every 60 days. A face-to-face meeting is not required for recertification.
- Patient receives care from a Medicare-certified home health agency (HOME HEALTH).
The patient cannot qualify for Medicare home health coverage if he or she needs more than intermittent nursing care[vii] or if the patient only needs occupational therapy. However, if he or she qualifies for home health care on another basis, he or she can also get occupational therapy. When the other home health needs end, the patient can continue receiving Medicare-covered occupational therapy under the home health benefit if you need it.[viii]
The following services are covered:[ix]
- Part-time or intermittent skilled nursing care
- Part-time or intermittent home health aide care
- Physical therapy
- Occupational therapy
- Speech-language pathology services
- Medical social services
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Table 1: This table summarizes the regulation requirements of each PAC facility at a high-level.
Long Term Acute Care
Acute Care Level Services
LOS > 25 Days
|Inpatient Rehabilitation Facility
60% Admit Dx Rule
3-hour Therapy Rule
|Skilled Nursing Facility
||3 Midnight Rule
|Home Health Agency
[i] Inpatient rehabilitation hospital care. Medicare Interactive. https://www.medicareinteractive.org/get-answers/medicare-covered-services/inpatient-hospital-services/inpatient-rehabilitation-hospital-care. Accessed May 29, 2019.
[ii] Skilled nursing facility (SNF) care. The Official U.S. Government Site for Medicare. https://www.medicare.gov/coverage/skilled-nursing-facility-care.html. Accessed May 29, 2019.
[iii] Medicare Payment Advisory Commission. March 2017 Report, Chapter 11. Long-term care hospital services. http://www.medpac.gov/docs/default-source/reports/mar17_medpac_ch11.pdf?sfvrsn=0. Published March 2017. Accessed May 29, 2019.
[iv] CMS calculates the LTCH average length of stay by only using Medicare fee-for-service cases that are not paid the site-neutral rate. (http://www.medpac.gov/docs/default-source/reports/mar17_medpac_ch11.pdf?sfvrsn=0)
[vi] Home health services. The Official U.S. Government Site for Medicare. https://www.medicare.gov/coverage/home-health-services.html. Accessed May 29, 2019.
[vii] Home health services. The Official U.S. Government Site for Medicare. https://www.medicare.gov/coverage/home-health-services.html. Accessed May 29, 2019.
[viii] Home health services. The Official U.S. Government Site for Medicare. https://www.medicare.gov/coverage/home-health-services.html. Accessed May 29, 2019.
[ix] Home health services. The Official U.S. Government Site for Medicare. https://www.medicare.gov/coverage/home-health-services.html. Accessed May 29, 2019.