For years, confusion has surrounded the conditions under which seniors can receive physical, occupational and speech therapy included in Medicare.
Services have been terminated for some seniors, for example those with severe installments of multiple sclerosis or Parkinson's disease, because therapists said they weren't making sufficient progress. Others, including individuals dealing with strokes or traumatic brain injuries, have been told they reached an annual limit on services and didn't be eligible for a further care.
Neither explanation stacks up to scrutiny. Medicare doesn't need that older adults demonstrate improvement in order to receive ongoing therapy. Nor will it limit the quantity of medically necessary therapy, for the most part.
The February congressional budget deal eases long-standing concerns by lifting a threat that some kinds of therapy might be restricted. But potential barriers to accessing this kind of care remain. Here's a take a look at how Medicare now covers such services.
Medical necessity. All therapy included in Medicare should be deemed “reasonable and essential to treat the individual's illness or injury,” require the services of skilled professionals and become susceptible to medical oversight.
What isn't a precondition for receiving services is ongoing improvement – getting measurably better. Although this could be a goal for therapy, other goals can include maintaining an individual's current abilities or preventing deterioration, based on a groundbreaking legal settlement in 2021.
The implication for older adults: If your therapist claims that she will not help you any longer since you aren't making substantial progress, you may well have grounds for an appeal. At the minimum, attorney at law with your physician about reasonable goals for treatments are advisable.
Part A therapy services. Often, older adults require therapy after an untoward event brings them to the hospital – for instance, a stroke or perhaps a bad fall. If a senior has an inpatient stay in a healthcare facility with a minimum of three days, she or he becomes eligible for up to 100 times of rehabilitation, including therapy, in a skilled nursing facility under Medicare Part A.
Therapy services covered by Medicare Part A also can be obtained within an inpatient, hospital-based rehabilitation facility. Within this setting, requirements demand therapy to be “intensive” – a minimum of three hours a day, five days per week. Stays are handled by Medicare up to a maximum 90 days.
If a senior returns home after finding yourself in a healthcare facility, he or she may receive therapy from a home health agency under Medicare Medicare part a. To qualify for home health care, a mature adult must need intermittent skilled services, for example those provided by a registered nurse or physical therapist, and be substantially homebound. Each episode of home healthcare can last as much as Two months and be renewed with a physician's authorization.
“A lot of home health agencies believe, wrongly, that the home health benefit, including therapy services, is restricted in duration to a couple of 60-day episodes,” said David Lipschutz, senior policy attorney at the Center for Medicare Advocacy. The conclusion for beneficiaries: You might want to advocate aggressively for the care you think you'll need and enlist your personal doctor to intervene for you.
Part B services. Physical, speech and occupational therapy are also covered by Medicare Part B in private practices, hospital outpatient clinics, skilled assisted living facilities (when a patient's Medicare part a benefits have run out) and, less often, in people's homes (when folks no more be eligible for a Medicare part a home health services but still need assistance).
More than 5 million older adults and people with disabilities covered by Medicare receive “outpatient” therapy services of the kind each year. Care can last up to 3 months, with the potential for renewal if a physician certifies that ongoing services are essential.
Questions about coverage for Part B therapy services have surfaced repeatedly since Congress authorized annual limits around the care that Medicare would cover in 1997 – a cost-saving move.
Faced with criticism, Congress delayed implementation of these “caps” for quite some time. Then, in 2006, it created an “exceptions” procedure that allowed caps to become exceeded, as long as therapy was judged to be medically necessary.
The exceptions process had two steps. First, a therapist had to request that services be extended whenever a patient reached an initial “cap” – set this year at $2,010. Then, another request needed to be made whenever a patient reached another, higher threshold – initially set at $3,700 this year, but reduced to $3,000 in the budget legislation. (There is a $3,000 threshold for physical and speech therapy, combined, and a separate $3,000 threshold for occupational therapy.)
Both steps called for therapists to warrant additional services by giving extra documentation. At the second, higher threshold, therapists also faced the prospect of intensive medical overview of their practices and, potentially, audits.
At that time, therapists were often hesitant to pursue exceptions, that has made it hard for patients with complex health conditions to access care. Also, sometimes requests for exceptions have been denied, posing another barrier.
“We make use of the exceptions process, but we've attempted to be very vigilant in who we tried on the extender for,” said Sarah Gallagher, an actual therapist at South Valley Physical rehabilitation in Denver, which focuses on treating people with complicated neurological conditions. “The risk is putting your clinic in danger of an audit should you ask for exceptions all too often.”
With February's budget deal, Medicare has gotten eliminate the “caps” but retained the idea of “thresholds.” After billing for $2,010 in services (about 20 therapy sessions at $100 per visit) this season, a service provider needs to add an extra code to some bill. After billing $3,000, targeted medical reviews and also the potential for audits can again be prompted.
Eliminating the caps should make things easier for seniors who need a time-limited course of therapy. But whether therapists is going to be wary about approaching the $3,000 threshold, with its extra administrative burdens and potential risks, remains to be seen. If so, patients recovering from strokes or brain injuries and those with complicated chronic conditions, who need intensive therapy for an longer timeframe, could be affected.
“We fear that there still might be barriers to accessing care,” said Lipschutz, of the Center for Medicare Advocacy. “We suspect some providers will say I'd rather not deal with this process, and if I'm getting anywhere near that $3,000 threshold, I'm just going to give it up.”
“Theoretically, all the uncertainty we have been coping with, associated with the therapy caps and acceptable goals of therapy, continues to be resolved,” said Kimberly Calder, senior director of health policy in the National Multiple Sclerosis Society. “But only time will tell.”