Rehabilitation & Skilled Nursing
Rehabilitation and skilled nursing services are specialized medical services intended to maintain, restore, improve, or prevent the deterioration of daily living functions and skills that have been lost or impaired due to illness, injury, or disability.
These services are designed for seniors aged 65 and older, individuals with disabilities eligible for Medicare, and anyone recovering from surgery, illness, or injury with the goal of returning to daily life and achieving independent living.
Key Services
- Skilled Nursing: Procedures requiring the skills of a nurse or specialized therapist, such as intravenous (IV) therapy, wound care, feeding tube management, and monitoring of diabetes or complex conditions.
- Physical Therapy: Improving mobility through gait training, muscle strengthening, and restoration of joint range of motion.
- Occupational Therapy: Functional rehabilitation for independent living, including eating, dressing, and grooming.
- Speech Therapy: Restoration of communication skills and treatment for swallowing disorders (dysphagia).
Cost and Coverage
Insurance coverage depends on the specific level of care you receive. Medicare classifies rehabilitation into two distinct settings based on the intensity of care needed:
- Skilled Nursing Facilities (SNF): Short-term skilled nursing and therapy care provided at a nursing home.
- Inpatient Rehabilitation Facilities (IRF): An inpatient rehab hospital or unit for those requiring intensive therapy.
Medicare (Part A) — Short-term Rehabilitation
Coverage Conditions (Must meet all 4):
- 3-Day Inpatient Stay (SNF Only): A minimum of 3 consecutive days of formal hospital Inpatient Admission is required before entering SNF(the day of discharge does not count). Time spent in the Emergency Room or under Observation Status is excluded from the count. This requirement does not apply to IRF.
*Confirm your inpatient status with the hospital. - Admission within 30 Days: Patients must enter SNF within generally 30 days of hospital discharge.
- Provider Certification: A physician or healthcare provider must certify that you require daily skilled nursing or intensive rehabilitative therapy provided by or under the supervision of professional staff.
- Medicare-Certified Facility: You must receive care at a Medicare-certified facility.
Out-of-Pocket Costs (Based on Benefit Period)
- Skilled Nursing Facilities (SNF)
- 1~20 days: $0/day (given $1,736 deductible already spent at inpatient care).
- 21~100 days: $217/day coinsurance
- Inpatient Rehabilitation Facilities (IRF): An inpatient rehab hospital or unit for those requiring intensive therapy.
- Covered under Part A with the same cost structure as a hospital stay
- 1–60 days: $0/day after paying $1,736 deductible
- 61-90 days: $434/day
- 91 days+: $868/day; Lifetime Reserve Days is used when beyond 91 days at IRF.
*Benefit Period Note: A Benefit Period ends when you have not received SNF care for 60 consecutive days. A new period requires a new $1,736 deductible.
*Doctor services while at SNF/IRF are covered under Medicare Part B.
*Out-of-pocket costs change annually; check Medicare.gov for the latest amounts.
*For details, check Medicare Part A/B.
Medicare Advantage (Part C) & Private Insurance
- Prior Authorization: Most Medicare Advantage and private insurance plans require Prior Authorization prior to admission.
- For beneficiaries enrolled in Medicare Advantage, the 3-day inpatient hospital stay requirement may be waived.
- Benefits typically apply only when using in-network facilities.
*Prior authorization process and inpatient stay requirements vary by plan; please check your own plan for specific requirements.*For details, check Medicare Part C.
Medicare Supplement Insurance (Medigap)
Depending on the specific plan, Medigap can cover the $217 daily coinsurance for days 21–100 in full or in part. Since coverage varies by plan type, it is essential to verify these benefits before enrolling.
*Medigap does not cover non-medical long-term residency costs (custodial care, room and board) at SNF.
*For details, check Medigap.
Medicaid (NJ FamilyCare)
Unlike Medicare, Medicaid (NJ FamilyCare) beneficiaries incur no out-of-pocket costs for services at Skilled Nursing and Rehabilitation Facilities. However, if care transitions from short-term rehab to long-term residency, coverage shifts to the Managed Long-Term Services and Supports (MLTSS) program.
- For NJ FamilyCare beneficiaries aged 64 and under, if rehabilitation becomes prolonged and exceeds the 100-day threshold, a Resource Test (Asset Review) will be applied. While NJ FamilyCare waived asset limits, MLTSS has strict asset limitations ($2,000 for individuals, $3,000 for married couples). Proactive financial planning is encouraged to ensure eligibility and coverage.
*For details, check ACA Medicaid.
Private Pay
If insurance benefits have ended or an individual does not meet eligibility requirements for assistance, they must pay for care directly. This includes lodging, meals, and care costs, which vary significantly by region and facility.
Find a Rehab & Skilled Nursing Facility
Major Rehab & Skilled Nursing Facilities in Bergen County
References
