For years Medicare rehabilitation therapy stopped when a patient no longer showed improvement. In 2013 this standard was changed. A court ruled that patients did not need to show improvement to continue therapy. They could continue if curtailment could cause a person’s condition to decline.
How a 76 year-old Wheelchair-Bound Woman Changed Medicare published in the Courier Life June 5-11, 2015 issue
Sometimes all you need is one determined woman to change the lives of millions of seniors. Glenda Jimmo, a 76 year-old, blind wheelchair bound woman did just that; she improved Medicare’s rehab policy for millions of infirmed seniors. In 2011 Ms. Jimmo filed a class action suit against Medicare after being denied rehabilitation therapy. She was informed that she was no longer eligible for physical and occupational therapy because she was not making progress with the therapy she was receiving. In rehab language she had “plateaued”.
Ms. Jimmo could not understand this reasoning. She had her right leg amputated due to complications from diabetes and was confined to a wheelchair. She required intense rehab therapy to improve her physical abilities. She knew her condition would deteriorate if she did not continue.
Thousands of rehab patients face similar situations everyday. Since Medicare’s creation in 1965, Medicare has stuck to an improvement standard policy that states once a person stops showing progress in physical, occupational or speech therapy, treatment will stop. This policy is particularly harmful for chronically ill patients who require continuous therapy in order to maintain an optimum level of health. When their therapies are discontinued their condition deteriorates.
Ms. Jimmo, a resident of Bristol Vermont, decided to challenge this decision and filed a class action suit against Medicare. This landmark case, Jimmo v. Sebelius ,changed the lives of millions of chronically ill seniors throughout the United States. On January 23, 2013, the U.S. District Court for the District of Vermont decided in Ms. Jimmo’s favor. The Court ruled that nowhere in Medicare’s policy manual is there a clause requiring a person to show improvement in order to continue receiving skilled treatments through Medicare. In fact the court determined that Medicare must cover therapy services that helps a person maintain his or her ability to function. As a consequence of this settlement patients with chronic conditions can now continue to receive physical and occupational treatment in and out of a rehab facility.
One woman expressed her relief upon hearing this decision. Her 80-year-old father, Sam, is in the mid-stages of Alzheimer’s disease. He is having a progressively harder time with balance and muscle control and needed physical therapy to help him with steadiness and coordination. She explained that Sam’s physical therapy keeps his muscles limber. However after a month of rehab, his therapists deemed he had “plateaued ” and his treatment was discontinued. As soon as he stopped, Sam’s arm muscles tighten to the point where his whole arm began to contract. The therapy had helped relieve the tension in his arms and allowed him to straighten them. “I don’t know what I would do if I could not get him relief from the strain.”
This court’s decision does not mean that a patient can continue receiving physical, occupational or speech therapy indefinitely. A person receiving rehab in a nursing home can get up to 100-days of Medicare financed therapy. The first 20 days are paid in total. After that Medicare pays 80% of additional therapy starting on day 21 and continuing up to 100 days. The remaining 20% is covered by a secondary health plan.
Upon leaving a rehab facility a person can continue to receive out-patient rehabilitation, however it is not as intense as the treatments received in a rehab facility. In-house therapy includes two 30 to 45 minutes sessions a day. A person receiving rehab at home gets the same amount of time per visit but usually gets therapy approximately three days a week.
In 2015, Medicare covers up to $1,940 for outpatient physical and speech therapy combined, and another $1,940 for occupational therapy. If a patient is approaching this limit and a doctor or therapist feels more therapy is required, a doctor or therapist can tell Medicare that it’s medically necessary to continue. With proper documentation from the provider, Medicare may cover additional therapy. If Medicare denies the claim, the decision can be appealed.
All the information on how much, how often and under what conditions a person can be receive rehabilitation therapy paid by Medicare is publicly available by referencing The Center for Medicare and Medicaid Services (CMS) Policy Manual on Medicare. Unfortunately what is written and what is provided is not always the same. Even today many rehab facilities are unaware of the Jimmo v. Sebelius ruling and deny patients adequate coverage. It is important that every person be aware of his or her rights under Medicare. It takes people like Ms. Jimmo to challenge unsubstantiated policies like Medicare’s “improvement standard” and demand their rights. And it is up to consumers like you to insure you get the amount of care you deserve.