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.”
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.”
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.”
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.”
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.