Have you been denied rehabilitation therapy because your medical condition was no longer improving?
In the past, in order for Medicare to pay for occupational therapy (OT), physical therapy (PT) and speech-language therapy (SLP) services, Medicare required that these services help you to improve or regain your ability to perform these functions. If your progress slowed down too much or stopped, then Medicare would no longer cover its share of the cost. If you simply wanted to continue therapy for maintenance of your condition, you would be responsible for the full cost of therapy.
The problem with this is that the law did not require a person’s condition to improve in order for Medicare to pay for rehabilitation therapy. People were being denied the coverage that they were entitled to receive.
A legal agreement, Jimmo v Sebelius, settled this and determined that Medicare is required to cover the costs of rehabilitation therapy for qualified individuals who receive therapy for maintenance of their condition. The agreement applies to skilled maintenance services provided in all three care settings including Medicare home health, outpatient therapy and skilled nursing facility benefits and applies equally to Medicare Advantage as to the traditional Medicare program.
Specific language in the agreement states that “Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage.” The agreement is intended to clarify that when skilled services are required to provide care that is reasonable and necessary to prevent or slow further deterioration; coverage cannot be denied based on the absence of potential for improvement or restoration.
Medicare has not expanded coverage. They are providing coverage in situations where they should have been provided in the first place.
Patients must still meet certain requirements for any treatment to be covered, including:
- Medically necessary
- Appropriate and effective in treating the condition
- Provided by a skilled professional
- Reasonable in terms of frequency and duration.
The payment limits, called “therapy caps,” are still in effect as well.
The bottom line is that not all medical providers are aware of these Medicare coverage changes and you may still be denied coverage for rehabilitation therapy you need. You need to be aware of these changes and bring them to the attention of your provider. If you’re still being denied the rehab therapy you are entitled to, you or your doctor will need to contact Medicare to correct the claim.