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Caregivers, Know Medicare’s PT Rules

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medicareptrulesUntil quite recently there were rules governing what Medicare will reimburse if a qualified adult was prescribed physical therapy, occupational therapy or speech therapy.  Patients needed to show documented improvement if Medicare was going to continue to cover their therapy.  As with all insurance rules, a patient or the patient’s families could pay out of their own pockets for any services a provider may prescribe, but until this year, the government was not going to pay for therapy without an improved health status.  All that has changed now with a federal ruling that it is no longer necessary to show improved status to get reimbursed.

If you are a caregiver to an older loved one or someone else with special needs who is covered under Medicare, therapy now will be offered to maintain a patient’s present condition or to prevent “backsliding.”  Translated, Medicare now must recognize and support a patient who is attempting to stay as well and as active as they can be.  As a geriatric care manager, this is very gratifying as a large part of what we do is to help our clients to maintain a quality of life, because beyond a certain age improvement is simply not realistic.

Many of the old rules are still in place regarding where therapy may be received.  It can be received at an outpatient center, a therapist’s private office, in a nursing home or in a patient’s own home.  Authorization simply requires a doctor’s order, so make sure your physician knows about the change.  The same dollar caps on how much Medicare will cover still remain, and that is $1,900 a year.  And even residents of nursing homes who have used up their 100 days can still get coverage for therapy, so long as they do not exceed the cap for the therapy. This, too, can be challenged , in certain cases, so be sure to check in with a local office of the Centers for Medicare and Medicaid Services for the terms.  And claims for patients who may have been denied before this year may still be honored retrospectively back to the date when the lawsuit was first filed January 18, 2011.

For more information on:

  • the outpatient therapy cap limits,
  • getting exceptions to the cap limits,
  • who can give therapy services under the rules,
  • where therapy services can be received, and
  • how to find out what the therapy services will cost,

go to http://www.medicare.gov/Pubs/pdf/10988.pdf or call 1-800-MEDICARE (1-800-633-4227).  TTY users should call 1-877-486-2048.  To find a resource in your own state, just visit: http://www.Medicare.gov/contacts.

Charlotte Bishop is a Geriatric Care Manager and founder of Creative Care Management, certified professionals who are geriatric advocates, resources, counselors and friends to older adults and their families in metropolitan Chicago.  Please email your questions to ccbishop@creativecasemanagement.com.

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