Short-term rehabilitation (rehab) is post-acute care, typically provided in a Skilled Nursing Facility (SNF), designed to help an individual recover function after a serious illness, injury, or surgery. The goal is to restore the patient’s independence so they can return home safely. Medicaid, a joint federal and state program, offers coverage for these services, but access is highly conditional. Coverage is not automatic and depends entirely on the patient meeting state-specific financial criteria and a strict medical necessity standard. The rules for short-term rehab under Medicaid differ significantly from Medicare, and the benefit is generally provided as part of the state’s broader Nursing Facility Services.
Scope of Covered Rehabilitation Services
Medicaid covers short-term rehabilitation services when they are deemed “medically necessary” and provided in a Medicaid-certified Skilled Nursing Facility. This standard means the care must be required for the treatment of an illness or injury and must be specific, safe, and effective for the patient’s condition. The services covered typically include skilled nursing care and specialized therapies aimed at recovery.
Skilled nursing care involves services that can only be performed by a licensed nurse, such as intravenous (IV) medication administration, complex wound care, and monitoring of unstable medical conditions. For rehabilitation, this includes Physical Therapy (PT) to restore movement and strength, Occupational Therapy (OT) to relearn daily living activities, and Speech-Language Pathology (SLP) for swallowing or communication issues. The facility must develop an individualized plan of care to achieve the patient’s highest practicable physical, mental, and psychosocial well-being.
Unlike Medicare, which limits SNF coverage to 100 days per benefit period, Medicaid does not have a uniform federal duration limit for medically necessary short-term rehab. However, many states implement their own limits on the length of a short-term stay, often around 30 days. States may also require continuous utilization review to justify coverage continuation. This coverage is intended for recovery and is distinct from the long-term custodial care benefit.
Eligibility and Financial Requirements for Coverage
Accessing Medicaid for short-term rehabilitation requires satisfying both a clinical need and a financial need. The clinical requirement confirms the medical necessity of the SNF stay, requiring skilled nursing or rehabilitative services to treat an acute condition. The financial criteria determine if the individual meets the state’s low-income and limited asset standards.
Medicaid is a needs-based program, and financial eligibility rules vary significantly by state. Generally, eligibility requires that an individual’s income and countable assets fall below specific thresholds, often tied to the Federal Poverty Level (FPL). While ACA expansion covers adults below a certain income level, the asset limits for services like short-term rehab are often much stricter.
For individuals whose income slightly exceeds the state’s standard Medicaid limit, some states offer a Medically Needy program, often referred to as a “spend down.” This provision allows the applicant to use their medical bills to reduce their “effective” income to the eligibility level. The applicant must incur medical expenses, such as hospital or doctor bills, equal to the excess income amount before Medicaid coverage for the remaining medical costs, including the short-term rehab, begins for that certification period.
The asset test is equally important, requiring an individual’s countable resources, like bank accounts and investments, to be below a low limit that varies by state. Certain assets, such as a primary residence, a car, and personal belongings, are usually exempt from this calculation. Navigating these income and asset rules is complex, requiring careful review of the specific program rules in the state where care is sought.
Navigating the Authorization and Admission Process
Securing coverage for a short-term rehab stay involves a sequence of authorizations once financial eligibility is established. The process typically begins while the patient is still in the hospital, where the discharge planner coordinates the transfer to a Skilled Nursing Facility. A physician must issue a clear order for the SNF stay, detailing the required skilled services, such as physical therapy or IV medication.
A crucial federal requirement for any individual seeking admission to a Medicaid-certified nursing facility is the Preadmission Screening and Resident Review (PASRR). This screening assesses the patient for any signs of serious mental illness or developmental disability, ensuring that their needs can be met by the facility and that the SNF setting is the most appropriate level of care. This step must be completed regardless of the patient’s payer source.
In most cases, the state Medicaid agency or the managed care organization administering the benefit requires prior authorization (PA) before the patient is admitted to the SNF. The facility’s admissions or utilization review team, often working with the discharging hospital, is responsible for submitting the clinical documentation to justify the medical necessity of the stay. Continued coverage is not guaranteed, and the facility must participate in ongoing utilization reviews to demonstrate that the patient is making progress toward their recovery goals and still requires a skilled level of care.