Increased Scrutiny Surrounds Medicare Coverage

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PT, OT, speech therapy among professions in focus

Recently, some older adults have seen Medicare services terminated, specifically those with conditions such as multiple sclerosis and Parkinson’s disease, due to insufficient progress. Others have seen services halted due to supposedly reaching an annual limit on spending.

The only problem is that neither explanation holds water—Medicare has no standard for improvement shown, nor are there limits or ‘caps’ on medically necessary treatment.

For the sake of clarity, here is how Medicare determines coverage since the February budget agreement:

  • Medically necessary treatment. All treatment must be deemed “reasonable and necessary to treat illness or injury” while being subject to medical oversight. However, measurable improvement is not a prerequisite or qualifier for receiving further treatment.
  • Part A services. If a person on Medicare has an inpatient stay of three or more days in the hospital, he or she becomes eligible for up to 100 days of rehabilitation in a skilled nursing facility under Medicare Part A.

Therapy services covered by Medicare Part A also can be obtained in an inpatient, hospital-based rehabilitation facility. In this setting, requirements call for therapy to be “intensive”—at least three hours a day, five days a week. Stays are covered by Medicare up to a maximum 90 days.

Part B services are used to cover expenses once Part A benefits expire. More than 5 million older adults and people with disabilities covered by Medicare receive “outpatient” therapy services of this kind each year.

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About Author

Rob Senior
Rob Senior

Rob has 15 years of experience writing and editing for healthcare. He previously worked for ADVANCE from 2002 to 2012.

1 Comment

  1. Barbara Kornblau on

    I am curious where you are getting this data. Are you saying that CMS or the intermediaries are ignoring the Jimmo decision or that therapists are not writing notes that show these patients/clients require skilled care?

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