| Tue, Aug 06, 2013 @ 09:00 AM

Denied Rehab Therapy Just Because Your Medical Condition is Not Improving?

Posted by Medicare Made Clear

rehabilitation therapyMedicare Part B covers outpatient occupational therapy (OT), physical therapy (PT) and speech-language pathology (SLP) services. Until recently, in order for Medicare to pay for these services, Medicare required that these services help people regain or improve their ability to perform certain functions.

If the therapist or referring doctor evaluated the patient’s progress and if improvement had slowed down too much or stopped, then Medicare stopped paying its share of the cost. Medicare would not cover outpatient services that only maintained a level of functioning or only made a person feel better. If the problem got worse, the therapy would be covered. Otherwise, if you were not improving but you still wanted to continue therapy to feel better, you would have needed to pay the full cost yourself.

The problem with this is that the law did not require a person’s condition improve in order to get Medicare to pay for rehabilitation therapy. Yet, people were being wrongly denied the Medicare coverage they were due. The result? Jimmo v. Sebelius, a class-action lawsuit against Health and Human Services Secretary Kathleen Sebelius.

People will finally get the rehab they need

Filed on January 11, 2011, the Jimmo v. Sebelius legal agreement settles once and for all that Medicare is required to cover the costs of rehabilitation therapy for qualified individuals whose therapy only maintains their condition instead of improves it. This will help a lot of people who need the therapy just to feel better but whose condition will not improve.

According to the Center for Medicare Advocacy, Inc., The Jimmo v. Sebelius settlement agreement itself includes language specifying that “Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage.”

The settlement agreement is intended to clarify that when skilled services are required in order 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. As such, any actions undertaken in connection with this settlement do not represent an expansion of coverage, but rather, serve to clarify existing policy so that Medicare claims will be adjudicated consistently and appropriately.

This basically means that Medicare has not expanded coverage, they are just going to start providing coverage in situations where they should have been providing it in the first place.

Keep in mind that patients will still need to meet certain requirements for their therapy to be covered by Medicare. For example, the treatment must be:

  • 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 limits are $1,900 for OT and another $1,900 for PT and SLP combined. However, therapists can obtain an exception to allow additional care. There is no pay limit if therapy is part of a home health care plan.

Some Medicare Advantage plans apply the therapy caps and some don’t. Check with your specific plan to find out for sure.

The therapy caps apply to services received in the following settings:

  • Therapist or physician offices
  • Outpatient rehabilitation facilities
  • Outpatient hospital departments
  • Skilled nursing facilities (nursing homes)
  • Home, when not part of a Medicare-covered home health benefit

The Bottom Line

Not all medical providers are aware of these Medicare coverage changes and you may still be denied coverage for the rehab therapy you need. It’s important to be aware of these changes and to inform your medical provider of these changes. If you are still being denied the rehab therapy you are entitled to, you or your doctor will need to contact Medicare to correct the claim.

For more information, contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. If you have questions about Medicare Made Clear, call 1-877-619-5582, TTY 711, 8 a.m. – 8 p.m. local time, seven days a week.


Medicare’s ‘improvement standard’ for physical therapy has changed:  by Susan Jaffe, The Washington Post (washingtonpost.com)

Frequently Asked Questions: Improvement Standard and Jimmo News: Center for Medicare Advocacy, Inc. (medicareadvocacy.org)

Improvement Standard and Jimmo News: Center for Medicare Advocacy, Inc. (medicareadvocacy.org)

Y0066_130801_110044 Accepted