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!
We are excited to share that June Smith, supervisor of OT services at Cardinal Cushing Centers and occupational therapist at South Shore Therapies, is coming on board to teach a new workshop this fall. Some of you may have attended her “Integrating Movement-Based Learning into the Classroom and Therapy” breakout session during 2012’s Therapies in the School. Thanks to your helpful feedback, we learned that there is great interest in participating in a two-day workshop on this topic. Her new course will focus on an expansive variety of movement-based techniques, and the evidence supporting use of these techniques, to help children enhance gross and fine motor skills in the classroom and in therapy. Some of the many techniques you will be able to immediately apply in your practice setting include Brain Gym, Bal-A-Vis, and Occular-Motor and Listening strategies.
We are working with June on developing the course now, and we need your help in deciding on a good title for this new workshop. We would be grateful for any ideas you may have for the title of this new course, as well as any techniques you are eager to learn. We look forward to hearing from you!
Vote for one of these titles or suggest your own:
- Learning Moves that make a difference- An Evidence-based Approach .
- Brain Moves
- Therapeutic Learning Connection
- Integrating Movement-Based Learning into the Classroom and Therapy
Please post your thoughts and suggestions below
Posting from Distinguished Faculty
It is important for all preschool and kindergarten children, and elementary classes that include children with special needs, to provide frequent music and movement breaks. The movement breaks take five minutes or less and children are taught to resume working after the activity. The rules are “don’t touch any body, don’t touch anything, and get back to school work after the break or we won’t do it tomorrow (but will try again the next day).
Social skills are enhanced by playing songs like “Help” by the Beatles or “Respect” by Aretha Franklin, letting children dance, then asking them to draw a picture with a caption describing how they show respect or areas in which they need help.
John Pagano presents his course:
Effective Ways to Manage Behavior and Increase Functional Outcomes in Autism and Sensory Processing Disorders
April 26-27, 2013 – Puyallup, WA
September 20-21, 2013 – Orland Park, IL
October 18-19, 2013 – Cedar Knolls, NJ
November 8-9, 2013 – Hollywood, FL
DEAR ERI COMMUNITY: Hello! I am a pediatric physical therapist (Early Intervention) currently struggling with a little girl (19 months old); significant hypotonia, NO head control, dislocating joints (elbows, shoulders, hips and knees), joint contractures in lower extremities, minimal movement, can roll to her side, no other gross developmental milestones met, bright girl, tracking, babbling and responding to her name and to simple verbal requests with vision and limited upper extremity movements in a supine position or supported in her xpanda chair. Has seen multiple specialists on the east coast and all are scratching their heads. MD has been ruled out, SMA ruled out. Is feeding via g-tube but has nice oral motor munching patterns and drinks from a straw. Thoughts on activities for promoting more head control or muscle activation. Cannot stress this enough, NO head control at this point. Have used a Hensinger, Miami J, and DMO suit to supplement supported sitting activities.
Thanks for any input.
As PTs, OTs and Speech language pathologists we know how detrimental to our patients’ health it can be when they don’t receive the appropriate amount of therapy and care. But for many of our patients this has become the norm as co-pays have skyrocketed to 80 – 85% of the cost of the visit.
While many of our patients can’t afford to go without therapy, it’s become a truth that many patients simply can’t afford the prescribed amount of therapy. We hear the struggles everyday. “I just can’t afford it,” “My insurance doesn’t cover it,” and so on. As therapists this can be very frustrating. We are trained to help, yet our hands are tied.
However, there may be some good news on the horizon. According to a recent article in Kaiser Health News, States are hearing our pleas for proper insurance coverage for Physical, Occupational and Speech Therapy. Therapists are backing proposals in several states to limit the amount an insurer can require patients to pay for therapy. New York, Pennsylvania, and Missouri have pending proposals currently and lawmakers in South Dakota and Kentucky have already passed these measures.
While insurance companies worry that these regulations may ultimately increase premiums, as therapists we believe that it may stave off the need for surgeries and further prescription drug treatments potentially reducing overall health costs.
Are you experiencing the same problems in your practice with patients’ inability to afford treatment? Has this affected the viability of your practice?
Read the full article, “States Consider Limiting Patient Costs for Physical, Speech, Occupational Therapy” and let us know your thoughts!