Medicare Patients Get More PT, Skilled Services

Patients caught in a Catch-22 requiring them either to improve when receiving physical therapy (PT) or skilled nursing services, or to lose Medicare coverage for the services, will see the double-bind end soon, thanks to a settlement in a suit against Health and Human Services (HHS) Secretary Kathleen Sebelius this year.

The class action suit, Jimmo v. Sebelius, addressed the “improvement standard,” which required a patient to improve when receiving skilled care for continued coverage of that care. The rule left elderly and disabled patients without skilled care if they weren’t improving, and that exacerbated many of the problems being treated, according to patient advocates.

The agreement gives the Centers for Medicare & Medicaid Service (CMS) until the beginning of 2014 to modify its manuals and educate beneficiaries and providers. It also requires CMS to review a random sample of skilled nursing facility, home health, and outpatient PT coverage decisions to identify trends and problems. It also calls for a review of individual claims determinations that may not have been made in accordance with the settlement agreement.

According to the Kaiser Health News, skilled nursing services are now covered when “necessary to maintain the patient’s current condition or prevent or slow further deterioration.” The agreement says Medicare covers PT, occupational therapy, and speech therapy at home, in a SNF or at a therapist’s private office to maintain the patient’s condition and prevent decline. The settlement makes clear that coverage does not depend on the “potential for improvement from the therapy but rather on the beneficiary’s need for skilled care.”

However, it does not change other criteria for coverage: Patients still need a doctor’s order indicating that treatment is medically necessary, and therapy must be provided or supervised by a trained professional. Also, payment caps on therapy remain in effect. Medicare will pay up to $1,900 this year for physical and speech therapy, and another $1,900 for occupational therapy.

Kaiser further says the agreement might have a major impact on seniors with chronic illnesses who want to remain in their homes, by ensuring that Medicare covers skilled care available there. These services include therapy, mental health counseling, and nursing care. To be eligible, Medicare requires that the patient be home bound—although not necessarily confined to bed. Visiting nurses (but not family caregivers) are covered for services at home, including administering intravenous drugs or wound care. There is no time limit for home care if the amount of skilled care is reasonable and not given daily, if it is provided by a trained professional, and if the patient has a doctor’s order indicating that treatment is medically necessary.

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