Medicare offers free physical therapy and occupational therapy but it takes some insider know-how to get the best results. Below are some tips that can insure you or your family member obtain the best rehab results possible.
Medicare provides several wonderful health services free of charge, including physical therapy, occupational therapy, and speech therapy after a stay in a hospital. Unfortunately many people do not benefit from these services because they do not know about them. Medicare physical therapy and occupational therapy are free but you must know the regulations to get the best care. Here are some facts:
*Medicare Part B pays for up to $3700 of physical, occupational and speech therapy in your home.
*Medicare Part A pays for up to 100 days for rehabilitation in a skilled nursing facilities.
*Rehab through Medicare A & B can be extended to maximize your recovery—if you understand the proper procedures.
But there are ways to extend your therapy past these caps. Read on to understand how.
What is Medicare Rehab?
For decades, Medicare has paid for rehabilitation services for the elderly and disabled. Medicare coverage includes physical therapy, occupational therapy, and speech therapy. Physical therapy (PT) works on the lower part of the body like the legs or feet. Physical therapists work on balance, walking, and transferring from one surface to another. Occupational therapy (OT) works on the upper body (hands and arms) and tasks such as buttoning clothes, bathing, combing hair, cooking, writing, etc. Speech therapy, also called speech and language pathology (SLP) focuses on swallowing and some talking issues. It involves retraining muscles used in swallowing that are weakened due to such illness as pneumonia or a stroke.
Rehabilitation can be conducted either in a skilled care facility (usually a nursing home), an outpatient clinic or medical office or in the patient’s home. Medicare Part A pays for nursing home rehab while Medicare Part B covers outpatient and in home treatment. Each Medicare has different requirements for continued coverage.
Traditional Medicare Part A pays for up to 100 days of skilled nursing home rehab. It pays 100% of the cost for the first 20 days of physical, occupational, and speech therapy, and 80% for the remaining 80 days. The other 20% payment comes out-of-pocket or through a secondary health insurance plan. Once the time cap is reached (100 days), Medicare stops all payment and any additional therapy must be paid privately or through a secondary healthcare plan.
This does not mean a person is guaranteed 100 days of rehab. The rehab staff is required to periodically assess each recipient and determine whether he is still eligible for treatment under Medicare guidelines. If the therapist determines the patient is no longer benefiting, treatment will cease and the patient is discharged from therapy before 100 days.
Medicare Part B pays for outpatient and in home therapy and has a financial cap for its services. After paying a yearly deductible, Medicare pays 80% of cost, and a secondary health insurance plan pay the remaining 20%. A therapist must periodically assess the client’s progress and can continue services until the client reaches a monetary cap of $1900 for physical and speech therapy (combined) and another $1900 for occupational therapy. If more therapy is needed this cap can be raised to $3700.
Maximizing Skilled Care Rehab
Most people do not know that Medicare caps are not as rigid as they initially appear. Here is some insider information that could help.
For decades the criteria for continuing or stopping therapy was decided by a “standard of improvement” policy, i.e. a person must continue to show progress during treatment. Once a person stops progressing, treatment is ended.
This criterion was recently challenged and changed. On January 24, 2013 the U.S. District Court for the District of Vermont approved a settlement agreement that declares that nowhere in Medicare’s policy is there a written statement that requires a person to stop therapy once they cease making progress. In fact, therapy should continue as long as the recipient continues to maintain his current status or if it slows any deterioration.
This new ruling has come as great news for thousands of individuals who are faced with chronic disabilities such as Multiple Sclerosis, Parkinson’s and Alzheimer’s disease. In the past, these people were refused continued rehab treatment even though therapy could help maintain their current capabilities. Now as long as a person can prove that the therapy is maintaining their current level of function, or that it is preventing deterioration, they have grounds to continue. This is a big coup for many patients!
Maximizing In home and outpatient rehab.
I spoke with Enrico Pasquarello Co-owner and CEO of Score Rehabilitation Physical and Occupational Therapy Services, PLLC a service covering home therapy in the five boroughs of New York City. Mr. Pasquarello explained that some patients might qualify for an exception to the $3700 cap if the therapist can document this need.
This second extension requires documentation that more therapy is needed. Then the recipient must sign a written notification, called an “Advance Beneficiary Notice of Non-coverage” (ABN), stating the patient is resubmitting this request with the understanding that if the request is denied the patient is responsible for the payment of the continued care. If the request is approved the therapy can continue free of charge.
In sum, Medicare offers some valuable health care services free of charge. Unfortunately many recipients never get the total benefit of these services because they are uninformed about what and how to ask for them. By understanding the policies regulating Medicare rehabilitation, a person can change the outcome of rehab from an okay recovery to a total recovery. Try it and see.
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