Plateau in Therapy No Longer Ends Medicare Coverage


Medicare coverage for therapy for people with chronic health problems and disabilities will no longer end when they don’t “progress”, as long as a doctor deems it medically necessary. 

A class-action lawsuit brought by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of four Medicare patients and five national organizations brought this issue to light and was settled in January, 2013. 

This ruling covers Medicare patients with chronic health problems and disabilities like Parkinson’s or Alzheimer’s disease, stroke, MS, and SCI etc. who are home-bound or in a nursing home. The hope is that it will delay costly nursing home admissions by enabling seniors to live longer in their own homes. In nursing homes, the duration of therapy is still limited to up to 100 days per “benefit period”, and they still have to spend at least three days as an inpatient in a hospital. 

The Medicare limits before the exceptions were $1900 for each of the therapies (PT, OT and SLP). Beneficiaries also often lose Medicare coverage for outpatient therapy when they hit this payment limit. But under the exceptions process Congress continued for another year, the health care provider can put an additional code on the claim that indicates further treatment above the $1900 limit is medically necessary. After $3700, the provider can submit more documentation to request another exception for 20 more sessions. 

Therapists: we’d love to hear your reaction to this new ruling. Tell us about some of your patients and how this will help them maintain their function!

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