Does Medicare Cover Rehab After Stroke?

Stroke can significantly impact an individual’s physical and cognitive abilities, often necessitating rehabilitation to foster recovery and improve quality of life. Medicare, the federal health insurance program, plays a substantial role in providing coverage for these services. Understanding this coverage is important for beneficiaries navigating healthcare after a stroke.

Types of Stroke Rehabilitation Covered by Medicare

Medicare covers rehabilitation therapies including physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services. Physical therapy focuses on restoring mobility, strength, and balance. Occupational therapy assists individuals in regaining the ability to perform daily activities, such as dressing, eating, and bathing. Speech-language pathology addresses communication disorders, swallowing difficulties, and cognitive impairments that can arise from a stroke.

These services can be provided in various settings. Inpatient Rehabilitation Facilities (IRFs), sometimes known as rehabilitation hospitals, offer intensive therapy in a hospital-like setting for individuals needing close medical supervision and coordinated care. Skilled Nursing Facilities (SNFs) provide a less intensive level of care for those not yet ready to return home from acute care. Both IRFs and SNFs offer a multidisciplinary approach to rehabilitation.

Medicare covers rehabilitation services in outpatient therapy clinics. Home health services can also bring therapies and skilled nursing care directly to a beneficiary’s residence if homebound and requiring intermittent skilled care.

Medicare Parts and Associated Costs for Rehab

Medicare’s coverage for stroke rehabilitation is structured across its different parts, each with specific cost-sharing requirements. Medicare Part A, known as Hospital Insurance, covers inpatient rehabilitation in facilities like Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs). For inpatient hospital stays, the 2025 deductible is $1,676 per benefit period. A benefit period begins the day a beneficiary is admitted as an inpatient to a hospital or SNF and ends when they have not received inpatient hospital or skilled nursing care for 60 consecutive days.

After the deductible is met, Part A covers the full cost for the first 60 days of an inpatient hospital stay. For days 61 through 90, a coinsurance of $419 per day applies, and for days 91 and beyond, the coinsurance is $838 per day, utilizing up to 60 lifetime reserve days. For skilled nursing facility stays, Part A covers the full cost for the first 20 days within a benefit period. From days 21 to 100, a daily coinsurance of $209.50 is applicable. After 100 days in a SNF within a benefit period, the beneficiary is responsible for all costs.

Medicare Part B, or Medical Insurance, covers outpatient rehabilitation services, including physical therapy, occupational therapy, and speech-language pathology, and some home health services. In 2025, the annual Part B deductible is $257. After meeting this deductible, beneficiaries pay 20% of the Medicare-approved amount for most Part B-covered services. This coinsurance applies to outpatient therapy visits and durable medical equipment.

Medicare Advantage Plans, also known as Part C, are offered by private insurance companies approved by Medicare. These plans must cover at least Original Medicare services (Parts A and B). However, Medicare Advantage plans can have different costs, rules, and network restrictions. They may also require prior authorization for certain services, including rehabilitation. Beneficiaries should review their specific plan details to understand coverage terms, copayments, and referrals.

Navigating Coverage Requirements and Appeals

Medicare coverage for stroke rehabilitation services hinges on several requirements, primarily medical necessity. All rehabilitation services, whether inpatient or outpatient, must be prescribed by a doctor and deemed medically necessary. This involves a physician-certified plan of care outlining therapies, frequency, and recovery goals. The plan of care should be regularly reviewed and updated to reflect progress and ongoing needs.

Medicare’s stance on improvement standards for therapy is that coverage does not necessarily require continuous improvement. Services can be covered if needed to maintain the beneficiary’s current condition, prevent decline, or slow further deterioration. This principle helps ensure access to therapies even when significant functional gains are not anticipated. The focus remains on whether the skilled services are reasonable and necessary.

Prior authorization may be a requirement for some rehabilitation services, particularly under Medicare Advantage plans. This involves obtaining approval from the insurance plan before receiving services. While Original Medicare rarely requires prior authorization for these services, Medicare Advantage plans frequently do for high-cost services, including inpatient hospital stays, skilled nursing facility care, and physical or occupational therapy. Failure to obtain prior authorization when required can result in coverage denials.

If Medicare denies coverage for rehabilitation services, beneficiaries have the right to appeal the decision. The appeals process involves multiple levels, beginning with a redetermination by the Medicare Administrative Contractor (MAC) for Original Medicare or a reconsideration by the Medicare Advantage plan. This initial appeal must be filed within 120 days of the denial notice.

If the denial stands, beneficiaries can pursue further appeals, including reconsideration by a Qualified Independent Contractor (QIC), a hearing before an Administrative Law Judge (ALJ), review by the Medicare Appeals Council, and ultimately, judicial review in federal court. Each level has specific deadlines and, for higher levels, may have a minimum amount in controversy requirement. Beneficiaries can seek assistance from State Health Insurance Assistance Programs (SHIPs) or other advocacy groups when navigating the appeals process.