Does Medicare Cover Inpatient Rehab After Knee Replacement?

Medicare, the federal health insurance program, provides coverage for inpatient rehabilitation following a knee replacement. This coverage is not automatic and depends on specific criteria. While Medicare Part A generally covers hospital stays and skilled nursing facility care, obtaining coverage for inpatient rehabilitation involves navigating various requirements and financial considerations. This process ensures rehabilitation services are medically appropriate and delivered in the correct setting.

Eligibility for Medicare Coverage

Medicare coverage for inpatient rehabilitation after a knee replacement hinges on meeting specific eligibility criteria, which vary depending on the type of facility. Rehabilitation can occur in a Skilled Nursing Facility (SNF) or an Inpatient Rehabilitation Facility (IRF), both of which have distinct requirements. A fundamental condition for either setting is that a doctor must certify the medical necessity for daily skilled nursing care or intensive therapy services.

Skilled Nursing Facility (SNF)

For coverage in a Skilled Nursing Facility, a qualifying hospital stay is generally required. This typically means an inpatient hospital stay of at least three consecutive days, not counting observation status or the day of discharge. The patient must then be admitted to a Medicare-certified SNF within 30 days of leaving the hospital. The care received in the SNF must be for a condition that was treated during the hospital stay or a new condition that developed while receiving SNF care for the original condition. The patient must also require skilled nursing or therapy services on a daily basis, meaning care that is so complex it can only be safely performed by, or under the supervision of, professional personnel.

Inpatient Rehabilitation Facility (IRF)

Coverage in an Inpatient Rehabilitation Facility (IRF) does not always require a prior three-day hospital stay, but it demands a higher intensity of rehabilitation services. An IRF is a specialized hospital or unit providing comprehensive, intensive rehabilitation programs. Patients admitted to an IRF must be able to tolerate at least three hours of intensive therapy per day, five days a week, or at least 15 hours within a seven-consecutive-day period. This intensive therapy must involve multiple disciplines, such as physical therapy, occupational therapy, and speech-language pathology, with at least one being physical or occupational therapy. Furthermore, a rehabilitation physician must supervise the patient’s care, conducting face-to-face visits at least three days per week to assess progress and modify treatment plans. The patient must also have a reasonable expectation of measurable improvement in their functional abilities.

Financial Responsibilities and Benefit Periods

Understanding the financial aspects and duration limits of Medicare coverage is essential once eligibility for inpatient rehabilitation is established. Medicare Part A covers inpatient hospital care, skilled nursing facility care, and inpatient rehabilitation facility care, but patients share in the costs through deductibles and co-insurance. The Medicare Part A deductible for each benefit period will be $1,676 in 2025. This deductible covers the patient’s share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period.

Skilled Nursing Facility (SNF) Costs

For Skilled Nursing Facility (SNF) stays, if all criteria are met, Medicare covers the first 20 days with no co-insurance. From day 21 through day 100 of extended care services within a benefit period, the daily co-insurance amount will be $209.50 in 2025. After day 100 in an SNF during a benefit period, the patient is responsible for all costs.

Inpatient Rehabilitation Facility (IRF) Costs

For Inpatient Rehabilitation Facility (IRF) stays, patients typically pay nothing for days 1-60 in a benefit period after the Part A deductible is met. A daily co-insurance amount of $419 applies for days 61-90, and $838 per day for lifetime reserve days (days 91-150), which are limited to 60 days over a beneficiary’s lifetime.

Benefit Periods

A benefit period is how Original Medicare measures the use of hospital and skilled nursing facility services. It begins the day a patient is admitted as an inpatient to a hospital or SNF and ends when they have not received any inpatient hospital care or skilled care in an SNF for 60 consecutive days. A new benefit period begins if a patient is readmitted after 60 days, requiring another Part A deductible. Medicare does not cover certain services, such as private duty nursing, personal items like toiletries, or a private room unless medically necessary.

Steps to Secure Inpatient Rehabilitation Coverage

Securing Medicare-covered inpatient rehabilitation typically begins with a healthcare professional’s assessment and referral. The hospital physician determines the necessity for inpatient rehabilitation services following a knee replacement and issues the appropriate orders. This initial assessment is crucial as it forms the basis for Medicare’s coverage determination.

The next step involves selecting a facility that is Medicare-certified. Both Skilled Nursing Facilities and Inpatient Rehabilitation Facilities must meet specific Medicare standards to be eligible for coverage. Patients or their families should confirm the facility’s certification to ensure services will be covered. During the admission process, patients will typically sign various forms related to their care and financial responsibility.

Patients have rights regarding their Medicare coverage, including the right to receive notices about coverage decisions. Hospitals are required to provide the “Important Message from Medicare” (IMM) to all Medicare inpatients, usually within two days of admission and again shortly before discharge. This notice informs beneficiaries of their rights, including the right to appeal discharge decisions or service terminations. If Medicare determines that services are no longer covered, or if a facility plans to discharge a patient, a “Notice of Medicare Non-Coverage” (NOMNC) will be issued, typically at least two days before services end.

Should coverage be denied or terminated, beneficiaries have the right to appeal the decision. A fast appeal can be requested, which involves an independent review by a Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO). This process is designed to provide a quick decision, often within a few days, especially if the patient believes services are ending too soon. It is important to note that Medicare’s coverage standard for skilled nursing or therapy services is based on the patient’s need for skilled care, including maintenance of function, not solely on the potential for improvement.