Maintain What You Gain



Over time, practically everyone — stroke survivor or not — loses some degree of function as they age. We cannot change the fact of that decline, but we can affect its rate. This is important for stroke survivors to remember, for without persistent effort on their part, they are likely to feel this decline more keenly.

A year or two out from therapy, it is not unusual for survivors to feel progress has stopped or that they’ve even lost some of their previous rehab gains. That would be a good time to get some more therapy. Think of this as “maintenance therapy,” and it is key to slowing the decline in function. For survivors on Medicare, it is actually part of their benefits.

Medicare Outpatient Therapy Cap

Until recently, and since 1997, there had been an annual cap on Medicare’s coverage of outpatient therapy. Fortunately, Congress enacted a permanent solution to the problematic cap on outpatient physical therapy services under Medicare Part B. Now, so long as therapy services are considered medically necessary, claims that go above the annually adjusted thresholds ($2,010 in 2018 for PT, SLP combined; $2,010 for OT) simply will require additional paperwork from the therapist to indicate to Medicare that the services are medically necessary and Medicare should pay for such services.

“Although there is a threshold, that is not a hard limit,” said Kara Gainer, director of Regulatory Affairs of the American Physical Therapy Association. “As long as the care is medically necessary and requires the skills of a therapist, it should be covered by Medicare. At the point at which services are no longer medically necessary, whether above or below the threshold, if the patient desires to continue to receive services, he or she will need to pay out-of-pocket,” Gainer said.

Medicare Coverage of Maintenance Therapy

It’s a myth that Medicare does not cover services to maintain or manage a beneficiary’s current condition when no functional improvement is possible. The 2013 Jimmo v. Sebelius court decision sought to dispel this misconception and provide clarifications to safeguard against unfair denials by Medicare contractors for skilled therapy services that aid in maintaining a patient’s current condition or to prevent or slow decline.

The CMS website summarizes the settlement this way: “Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program.”

Criteria for maintenance therapy essentially hinge on whether the skills of a therapist are required to maintain or prevent or slow a further deterioration in function. “It isn’t limited to any particular condition or disease, and there are no time limits,” Gainer said. “As long as the services are medically necessary, Medicare should pay for those services, even if the patient has exceeded the threshold.”

Kara Gainer

Survivor Gerhard Endress has taken advantage of this benefit every year since his stroke. “His neurologist writes a prescription for Medicare benefits to the PT and OT and requests more treatments,” said Gillian Endress, Gerhard’s wife. “They never suggest it, but I ask for it when we have an appointment. We get around 18 sessions, which we use once a week till they run out, and then we do private sessions once a week at a fitness center.”

Private insurance

Most private insurers tend to have limits on the number of therapy visits. Each payer is different, so each policy needs to be closely examined. “Most insurers impose some form of an ‘improvement’ standard, and hence would not cover maintenance therapy,” Gainer said. “They want to see improvement in function; maintaining or preventing a decline in function generally is not covered. However, with the increased focus on reducing opioid use, we are starting to see payers start to consider whether to expand coverage of nonpharmacological treatments, like physical therapy.”

Paying cash

If a stroke survivor is a Medicare beneficiary and wants maintenance therapy that is medically necessary, he can’t pay cash. A claim must be submitted to Medicare. “However, if the Medicare beneficiary wants therapy that would not be considered medically necessary, a therapist would need to issue an Advance Beneficiary Notice (ABN) before providing items or services that the therapist believes or knows Medicare may not cover. This must be signed by the patient prior to the time of service. By signing the ABN, the patient is acknowledging they know they could be required to pay out-of-pocket. The therapist may then ask the patient to pay out-of-pocket. Regardless, the therapist must submit a claim to Medicare with a modifier, indicating an ABN is on file,” Gainer said. “By submitting a claim, the therapist is complying with the Mandatory Claims Submission rule while also indicating to Medicare the patient’s acknowledgement the services are not medically necessary and hence, aware that Medicare will not pay for the services.”

Senior man getting physical therapy

As for private insurers, each insurer has different policies. However, if care is not covered, then generally, patients could pay cash for such services. Patients should check their in- and out-of-network policies to ensure that they understand their responsibility when services are not covered.


 


 

Stroke Connection. Download the free app today.


 


 

Edit ModuleShow Tags

Stroke Rehabilitation

Making the Best Decisions at Discharge After Stroke

The type of rehabilitation and support systems a survivor receives at discharge can strongly influence health outcomes and recovery. In this, the first part of a two-part series on stroke rehab, we offer guidance for the decision-making process required when it’s time to leave the hospital.

What to Expect from Outpatient Rehab

After stroke, about two-thirds of survivors receive some type of rehabilitation. Outpatient therapy may consist of Several types of therapy. Whether a patient is referred to inpatient or outpatient therapy depends on the level of medical care required.

What to Expect in Stroke Rehab

Following a stroke, about two-thirds of survivors receive some type rehabilitation. In this second of our two-art series, we want to alleviate some of the mystery, fear and anxiety around the inpatient rehab part of the stroke recovery journey.
Edit ModuleShow Tags Edit ModuleShow Tags

AHA-ASA Resources

The Support Network

When faced with challenges recovering from heart disease or stroke, it’s important to have emotional support. That is why we created a network to connect patients and loved ones with others during their journey.

Stroke Family Warmline

The Warmline connects stroke survivors and their families with an ASA team member who can provide support, helpful information or just a listening ear.

Let's Talk About Stroke Patient Information Sheets

Let's Talk About Stroke is a series of downloadable patient information sheets, created by the American Stroke Association, that presents information in a question-and-answer format that's brief, easy to follow and easy to read.

Request Free Stroke Information Packets

Fill out this online form to request free information about a variety of post-stroke topics.

Caregiver Guide to Stroke

The Caregiver Guide to Stroke is meant to help caregivers better navigate the recovery process and the financial and social implications of a stroke.

Tips for Daily Living Library

This volunteer-powered library gathers tips and ideas from stroke survivors, caregivers and healthcare professionals all over the country who’ve created or discovered adaptive and often innovative ways to get things done!

Stroke Support Group Finder

To find a group near you, simply enter your ZIP code and a mile radius. If your initial search does not pull up any groups, try
Edit ModuleShow Tags

Stroke & Parts of the Brain

When Stroke Affects the Parietal Lobe

The parietal lobe helps us make sense of sensory information, like where our bodies and body parts are in space, our sense of touch, and the part of our vision that deals with the location of objects.

When Stroke Affects the Frontal Lobe

Of the four lobes that make up the cerebral cortex, the frontal lobe is the largest. It plays a huge role in many of the functions that make us human — memory, language, movement, judgment, abstract thinking.

When Stroke Affects the Temporal Lobe

The temporal lobe has several functions, mainly involved with memory, perception and language.

When Stroke Affects the Brain Stem

The brain stem serves as a bridge in the nervous system. It sits at the top of the spinal column in the center of the brain. When a stroke happens there, it can cause a few different deficits and, in the most severe cases, can lead to locked-in syndrome.

When Stroke Affects the Thalamus

The thalamus can be thought of as a "relay station," receiving signals from the brain’s outer regions (cerebral cortex), interpreting them, then sending them to other areas of the brain to complete their job.
Edit ModuleShow Tags

Departments

Stroke Notes

Stroke-related news you can use about new scientific findings, public policy, programs and resources.

Readers Room

Articles, poems and art submitted by stroke survivors and their loved ones.

Life Is Why

Everyone has a reason to live a longer, healthier life. These stroke survivors, caregivers and others share their 'whys'. We'd love for you to share yours, too!

Everyday Survival

Practical tips and advice for day-to day living after stroke.

Life At The Curb

A unique perspective on survival by comedian and stroke survivor John Kawie.

Simple Cooking

Cooking at home can be a daunting task, but a rewarding one for your diet and lifestyle (and your wallet). Making small changes in your diet is important to your heart health. Here are simple, healthy and affordable recipes and cooking tips.

Support Showcase

Our new department highlighting the good work being done by stroke support groups from around the nation. If you are part of a successful support group we should consider featuring, let us know!