Medicaid is a joint federal and state program providing health coverage to millions of low-income individuals, families, and people with disabilities. Short-term rehabilitation, often called post-acute care or skilled nursing facility (SNF) care, is medical treatment provided for a limited time following an acute event or hospitalization. Medicaid does cover this care, but the coverage is highly conditional. It varies significantly based on state rules and the patient’s specific medical needs, requiring eligible individuals to meet both financial and medical criteria.
Scope of Covered Services
Medicaid coverage for short-term rehabilitation focuses on services provided in a Skilled Nursing Facility (SNF) setting. These facilities help patients recover and transition back home after a hospital stay. The benefit typically includes the cost of room and board, an expense not covered by Medicare after the initial days of a stay.
The core services covered must be “skilled,” requiring the training and expertise of a licensed professional. This includes skilled nursing care, such as complex wound care, intravenous medication administration, or monitoring unstable medical conditions. Rehabilitation therapies are also included, specifically physical therapy, occupational therapy, and speech therapy, all aimed at restoring function.
Medicaid typically covers skilled, restorative care, not “custodial” care, which involves only assistance with daily living activities like bathing and dressing. While coverage may extend to certain home health services, they must also be medically necessary and skilled. The specific bundle of services and the setting in which they are covered are defined by each state’s Medicaid State Plan.
Patient Eligibility Requirements
To access the short-term rehabilitation benefit, a patient must first meet Medicaid’s financial eligibility criteria, which includes limitations on income and countable assets. Beyond this, the patient must satisfy specific clinical requirements demonstrating the medical need for skilled care. The primary medical requirement is the need for daily skilled services that can only be provided in a skilled setting, such as a nursing facility.
A physician must certify this need, documenting that the patient’s condition requires continuous care from licensed nurses or therapists. The care must be directed toward improving the patient’s condition or maintaining their current status to prevent further deterioration. If the patient only requires help with daily activities and has no skilled medical or rehabilitative need, the care is classified as custodial. Custodial care may be covered by different Medicaid programs, such as those for long-term care, but not the short-term rehabilitation benefit.
Unlike Medicare, which requires a qualifying three-day inpatient hospital stay prior to SNF admission, Medicaid’s requirements for a prior hospital stay vary by state. However, the need for continuous skilled care remains the fundamental clinical standard. The patient’s medical documentation must clearly show that the intensity and nature of the services needed are beyond what can be safely or practically managed at home. A clinical team regularly assesses the patient to confirm the ongoing necessity of the skilled services.
State-Specific Duration Limits
Medicaid is administered through a partnership between the federal government and individual states, leading to significant variability in the duration of covered short-term rehabilitation stays. Every state determines its own limits for the time period covered under its “Medicaid State Plan Benefits.” Unlike Medicare, which provides a standard limit of up to 100 days of SNF care per benefit period, Medicaid has no uniform national standard.
States may limit coverage to a specific number of days per benefit period, such as 29 consecutive days, or they may continue coverage only as long as the patient meets medical necessity criteria. This duration is the maximum time frame available if the medical need continues, not a guarantee of coverage for the entire period. If a patient’s condition plateaus or they reach maximum medical improvement sooner, coverage for the skilled benefit ends, even if the maximum day limit has not been reached.
The state’s Medicaid agency or Managed Care Organization (MCO) performs continuous utilization reviews to justify the patient’s ongoing stay. If a patient is discharged from the skilled facility early and then requires re-admission, a new authorization process may be required, and the unused days from the original stay may not be recoverable, depending on the state’s specific rules. This constant review process ensures that coverage aligns strictly with the need for skilled, restorative care.
Securing Authorization for Coverage
The process for securing Medicaid coverage for short-term rehabilitation is generally initiated by the healthcare facility, often starting with the hospital’s discharge planning team. This team ensures the patient transfers to a Medicaid-certified Skilled Nursing Facility. The facility is responsible for submitting a request for “pre-authorization” to the state’s Medicaid agency or the patient’s Managed Care Organization (MCO).
The request must include a comprehensive clinical assessment, the physician’s certification of the need for skilled care, and a detailed plan of treatment. Authorization is not a one-time event; the facility must participate in ongoing utilization review to justify the continued stay. This involves regularly submitting documentation to the payer demonstrating that the patient is making progress or still requires daily skilled services.
Timely and thorough documentation is paramount, as any lapse in proving medical necessity can lead to a denial of continued coverage. Patients and their representatives should maintain open communication with the facility’s financial department to monitor the status of the authorization. The authorization confirms that the state agrees the care is medically necessary and meets the criteria of the state’s Medicaid plan.