How Long Does Medicare Pay for Rehab After Hip Replacement?

Rehabilitation following a hip replacement is a significant part of recovery. Medicare, the federal health insurance program, offers coverage for these services. This coverage is subject to specific rules and durations that beneficiaries need to understand to navigate care options and manage costs effectively.

Understanding Medicare Rehabilitation Coverage

Medicare provides coverage for rehabilitation services across various settings, with different parts of Medicare covering distinct types of care. The specific part of Medicare involved depends on the nature and location of the rehabilitation.

Medicare Part A covers inpatient care in settings such as a Skilled Nursing Facility (SNF) and an Inpatient Rehabilitation Facility (IRF). An SNF provides skilled nursing care and therapy services after a hospital stay. An IRF offers intensive rehabilitation services for those requiring a higher level of medical supervision and a coordinated team approach.

Medicare Part B covers outpatient rehabilitation services, including physical therapy, occupational therapy, and speech-language pathology. These services can be provided in various settings, such as clinics or hospital outpatient departments. Part B also covers doctor visits and other medical services.

Medicare Advantage Plans are offered by private companies approved by Medicare. These plans must cover all services Original Medicare (Parts A and B) covers. They may have different cost-sharing requirements, network restrictions, and prior authorization rules that can influence a beneficiary’s rehabilitation choices.

Inpatient Rehabilitation Coverage Specifics

Inpatient rehabilitation after a hip replacement involves specific criteria and durations for Medicare coverage in Skilled Nursing Facilities (SNFs) and Inpatient Rehabilitation Facilities (IRFs). These settings cater to different levels of care intensity and have distinct Medicare payment structures.

Coverage in a Skilled Nursing Facility is provided under Medicare Part A for up to 100 days per benefit period. A benefit period begins the day a person is admitted as an inpatient to a hospital or SNF and ends after 60 consecutive days without inpatient hospital or SNF care. For the first 20 days, Medicare covers 100% of approved costs. For days 21 through 100, a daily coinsurance of $209.50 applies in 2025.

To qualify for SNF coverage, a beneficiary must have a prior medically necessary inpatient hospital stay of at least three consecutive days. Admission to the SNF must occur within 30 days of leaving the hospital, and the care must be for a condition treated during the hospital stay or a new condition that arose while receiving SNF care. Daily skilled nursing or therapy services must be required and provided by a Medicare-certified facility.

In an Inpatient Rehabilitation Facility, Medicare Part A provides coverage, not limited to a specific number of days like an SNF. Coverage continues as long as care is medically necessary and the patient meets specific criteria for intensive rehabilitation. This includes participating in at least three hours of therapy per day, five days a week, across multiple therapy disciplines. The focus is on the patient’s ability to participate and make reasonable progress toward recovery goals.

For IRF stays, beneficiaries pay nothing for days 1-60 in a benefit period after meeting the Part A deductible ($1,676 in 2025). A daily coinsurance of $419 applies for days 61-90, and $838 per day for up to 60 lifetime reserve days beyond day 90. After lifetime reserve days are exhausted, the beneficiary is responsible for all costs.

Outpatient and Home Health Rehabilitation Coverage

Beyond inpatient stays, Medicare covers rehabilitation services in outpatient and home health settings, providing flexible options for ongoing recovery. These types of coverage are for individuals who do not require the intensity of inpatient care or prefer to receive services in their home. The structure and duration of coverage differ significantly from inpatient benefits.

Outpatient therapy, covered under Medicare Part B, includes physical, occupational, and speech-language pathology services. There are no longer financial caps on how much Medicare will pay for these medically necessary services, meaning coverage can continue as long as a qualified therapist determines they are needed. Patients pay 20% coinsurance of the Medicare-approved amount after meeting the annual Part B deductible ($257 in 2025). This allows for sustained therapy to aid in regaining strength, mobility, and function following surgery.

Home health care, covered under either Medicare Part A or Part B, provides intermittent skilled nursing care, physical therapy, occupational therapy, and speech-language pathology in a patient’s home. To qualify, an individual must be “homebound,” meaning leaving home requires considerable effort or is medically advised against. The care must be medically necessary and prescribed by a doctor. Coverage can continue as long as the care remains medically necessary and prescribed, provided the beneficiary meets eligibility criteria.

Addressing Ongoing Rehabilitation Needs

As individuals progress through rehabilitation after a hip replacement, questions may arise about continued care if standard Medicare coverage periods conclude. Medicare coverage for rehabilitation is tied to the need for skilled care, which can include services necessary to maintain a patient’s condition or prevent decline, not solely for improvement. This distinction is important for beneficiaries needing long-term support.

The “improvement standard,” which previously led to coverage denials if a patient was not expected to improve, was clarified by the Jimmo v. Sebelius settlement. This settlement affirmed that Medicare coverage for skilled nursing care, outpatient therapy, and home health services should be based on the need for skilled care to maintain a condition or slow deterioration. Even if a patient’s condition is stable or not improving, Medicare coverage may still be available if skilled services are required to prevent a decline. Documentation must support the need for skilled care to slow or prevent deterioration.

When Medicare coverage for rehabilitation services ends or is denied, several options exist for addressing ongoing care needs. Individuals may consider self-paying for continued services beyond Medicare’s covered benefits. Supplemental insurance plans, such as Medigap policies, can help cover out-of-pocket costs like deductibles and coinsurance. For those with limited income and resources, Medicaid may provide assistance with healthcare costs, including long-term care services not covered by Medicare.

Beneficiaries have the right to appeal Medicare coverage decisions if they believe their care is medically necessary. The appeals process involves several levels: initial determination, reconsideration, an Administrative Law Judge (ALJ) hearing, and potential further review by the Medicare Appeals Council and judicial review. If a beneficiary disagrees with a decision, they can appeal by following instructions on their Medicare Summary Notice or Explanation of Benefits. An expedited appeal process is available for situations such as when services are ending too soon.