1. Helping clients understand Medicare’s coverage of outpatient therapy services

2. Medicare Rights Center
The Medicare Rights Center is a national, nonprofit
consumer service organization that works to
ensure access to affordable health care for older
adults and people with disabilities through
Counseling and advocacy
Educational programs
Public policy initiatives

3. National Council on Aging
This toolkit for State Health Insurance Assistance
Programs (SHIPs), Area Agencies on Aging (AAAs),
and Aging and Disability Resource Centers (ADRCs)
was made possible by grant funding from the
National Council on Aging.
The National Council on Aging is a respected national leader and trusted partner to help people aged 60+ meet the challenges of aging. They partner with nonprofit organizations, government, and business top provide innovative community programs and services, online help, and advocacy.

4. Learning objectives
Review Medicare’s coverage of outpatient skilled therapy services
Apply knowledge to case studies to understand how to better counsel clients

5. Medicare and outpatient skilled therapy services

6. Basics
Services reasonable and necessary to treat illness or injury, performed by or under supervision of licensed therapist
Includes:
Physical therapy (PT)
Speech-language pathology (SPL)
Occupational therapy (OT)
Physical therapy includes gait training and supervision of and training for exercises to regain movement and strength to a body area. Speech-language pathology services include exercises to regain and strengthen speech and language skills. Occupational therapy helps individuals regain the ability to do usual daily activities by themselves, such as eating and putting on clothes.

7. Coverage requirements
Medicare Part B covers therapy services that help beneficiaries regain or maintain ability to function if:
Beneficiary needs therapy and it is considered safe and effective treatment
Must require services that can only be performed safely by or under supervision of licensed therapist
Licensed therapist or staff under therapist’s supervision must administer services
Beneficiary’s physician or therapist creates plan of care
Must regularly review plan of care
Medicare Advantage Plans must follow Original Medicare coverage rules, but may set different costs and impose network or other restrictions

8. Receiving care Beneficiaries can access outpatient therapy services:
From a private practice, Medicare-approved therapist during home or office visits
At Comprehensive Outpatient Rehabilitation Facility (CORF)
In an outpatient hospital setting
Therapy services are also covered:
Through the home health benefit
During Medicare-covered skilled nursing facility (SNF) stay
Medicare’s coverage rules for outpatient therapy do not apply if you are receiving therapy as part of a Medicare-covered SNF stay or if you are receiving Medicare-covered home health care.

9. Outpatient therapy costs
Original Medicare covers outpatient therapy at 80% of Medicare-approved amount
After total therapy costs reach certain amount, Medicare requires provider to confirm that therapy is medically necessary
In 2018, Original Medicare covers up to:
$2,010 for PT and SPL before requiring provider to indicate that care is medically necessary
$2,010 for OT before requiring provider to indicate that care is medically necessary
Costs may differ for beneficiaries in Medicare Advantage Plans
Remember, outpatient therapy includes therapy received:
At therapists’ or doctors’ offices
At CORFs
At SNFs, when you are there as an outpatient or are otherwise ineligible for a Medicare-covered stay
And, at home through therapists connected with home health agencies, when you are ineligible for Medicare’s home health benefit

10. Targeted medical review
Medicare contractor may review medical records for therapy claims after they reach a certain amount
Contractor checks that services are medically necessary
In 2018:
$3,00 for PT and SPL combined before claims are eligible for medical review
$3,000 for OT before claims are eligible for medical review
Claims above $3,000 are not automatically subject to targeted medical review

11. Appeal process If appeal is denied, there are further levels of appeal
If beneficiary’s care is ending, they should receive Notice of Medicare Non-Coverage
Individual should receive notice no later than two days before care is set to end
Beneficiaries who want care to continue should file expedited appeal with Qualify Improvement Organization (QIO) by noon of the day before care is set to end
QIO should make decision no later than two days after care was set to end
Provider cannot bill before the QIO makes decision
If appeal is denied, there are further levels of appeal

12. Coverage of maintenance services
Medicare covers SNF, home health, and outpatient therapy care regardless of whether beneficiary’s condition is temporary or chronic, or beneficiary is improving
Restoration potential is not needed for Medicare coverage
Improvement standard cannot be applied when Medicare is determining coverage of claims that require skilled care
Decided after class action lawsuit, Jimmo v. Sebelius, was settled in 2013
Although beneficiaries often hear otherwise, Medicare covers services that:
Help maintain ability to function
Help regain function or improve
Or, prevent or slow worsening of individual’s condition
For more information on Jimmo v. Sebelius and the improvement standard:

13. Case studies

14. Case study #1
Liz receives therapy through Medicare’s home health benefit. Her physician tells her that they need to stop her therapy because Medicare will no longer pay for it. When Liz asks why, they explain that she is no longer improving. The physician advises she pay out of pocket if she wants to continue her care.
What information should a counselor provide Liz to help?

15. Answer
Liz should be informed that the improvement standard should not be used as a justification for ending her therapy
Medicare will cover services that:
Help maintain ability to function
Or, prevent or slow deterioration
Advise that Liz show doctor’s Centers for Medicare and Medicaid Services (CMS) fact sheet on Jimmo v. Sebelius
Payment/SNFPPS/Downloads/jimmo_fact_sheet2_022014_ final.pdf

16. Case study #2
Damon receives physical therapy as part of his Medicare-covered SNF stay. However, his physicians informed him that he will exhaust Medicare’s SNF benefit* soon. He is concerned because they explained that he still needs PT.
What information should a counselor provide Damon to help?
*Medicare covers up to 100 days in a SNF each benefit period.

17. Answer
Damon should ask his providers if he is eligible for Medicare’s home health benefit
If he meets eligibility requirements, he can receive PT after discharge through home health benefit
If he is ineligible for home health, Damon can still receive medically necessary PT on outpatient basis
Option of getting PT at therapists’ or doctors’ office, or CORF
May continue receiving Medicare-covered PT at SNF on outpatient basis, but will be required to pay out of pocket for continued SNF stay

18. Conclusion

19. What you have learned
Medicare’s coverage rules for outpatient skilled therapy services
Counseling strategies via case studies

20. Resources for information and help
State Health Insurance Assistance Program (SHIP)
Social Security Administration
Medicare
1-800-MEDICARE ( )
Medicare Rights Center
National Council on Aging

21. Medicare Interactive www.medicareinteractive.org
Web-based compendium developed by Medicare Rights for use as a look-up guide and counseling tool to help people with Medicare
Easy to navigate
Clear, simple language
Answers to Medicare questions and questions about related topics
3+ million annual visits

22. Medicare Interactive Pro (MI Pro)
Web-based curriculum that empowers professionals to better help clients, patients, employees, retirees, and others navigate Medicare
Four levels with four to five courses each
Quizzes and downloadable course materials
Builds on 25 years of Medicare Rights Center counseling experience
For details, visit center/courses or contact Jay Johnson at or