At a time of year when everyone is focusing on springing forward, it is also important to remember that some of the patients that we serve daily have a skilled need to maintain.
Skilled services, after all, must be provided with the expectation, based on the assessment made by the physician of the patient’s restoration potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time, or the services must be necessary for the establishment of a safe and effective maintenance program, or the services must require the skills of a qualified therapist for the performance of a safe and effective maintenance program.
Maintenance therapy and the allowances for rehab professionals gained a greater appreciation following the Jimmo versus Sebelius settlement.
The Jimmo Settlement Agreement clarified that when a beneficiary needs skilled nursing or therapy services under Medicare’s skilled nursing facility, home health (HH) or outpatient therapy (OPT) benefits in order to maintain the patient’s current condition or to prevent or slow decline or deterioration (provided all other coverage criteria are met), the Medicare program covers such services and coverage cannot be denied based on the absence of potential for improvement or restoration.
Based on this, the Medicare program covers such services, and coverage cannot be denied based on the absence of potential for improvement or restoration.
In short, what the settlement agreement and the resulting revised manual provisions clarify is that Medicare coverage for skilled nursing and therapy services in these settings does not “turn on” the presence or absence of a beneficiary’s potential for improvement, i.e., it does not matter whether such care is expected to improve or maintain the patient’s clinical condition.
Therapy services in connection with a maintenance program are considered skilled when they are so inherently complex that they can be safely and effectively performed only by or under the supervision of a qualified therapist (see 42CFR 409.32)
So how does the definition of rehab therapy differ from maintenance therapy?
Rehab Therapy
Rehabilitative/Restorative therapy includes services designed to address recovery or improvement in function and, when possible, restoration to a previous level of health and well-being (i.e. PLOF).
Therefore, evaluation, re-evaluation and assessment documented in the Progress Report should describe objective measurements which, when compared, show improvements in function, decrease in severity or rationalization for an optimistic outlook to justify continued treatment.
Maintenance Therapy
MAINTENANCE PROGRAM (MP) means a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness.
Maintenance Program
Great, now that we have the definitions down, let’s consider some of the top questions that rehab professionals have around maintenance care.
Question: Are professional therapy services available under Medicare only for patients who are improving or who are expected to improve?
Answer: No. The Jimmo Settlement confirms that services by a physical therapist, occupational therapist, and speech and language pathologist are covered by Medicare, Parts A and B, and by Medicare Advantage Plans in skilled nursing facilities, home health and outpatient therapy, when the services are necessary to maintain a patient’s current condition or to prevent or slow a patient’s further decline or deterioration.
Question: What qualifies a patient for therapist-provided maintenance services under the Medicare benefit?
Answer: Since maintenance services are considered skilled care, the patient must meet the setting-specific qualifying criteria outlined in the law, regulations, and Medicare Benefit Policy Manual. Once those criteria have been confirmed, the qualified therapist will, after completion of a thorough assessment of the patient, select the focus of care in collaboration with the physician. If the patient is currently at a point where material improvement is not expected and decline is probable without skilled therapy care, a maintenance course of care may be developed and implemented.
Question: Does Jimmo apply only to specified medical conditions, such as multiple sclerosis and Parkinson’s disease?
Answer: No. The Settlement is not limited to any particular condition or disease. It applies to any Medicare patient who requires skilled nursing or skilled therapy to maintain the patient’s current condition or to prevent or slow the patient’s further decline or deterioration, regardless of the patient’s underlying illness, disability, or injury. The Settlement is not limited to people with chronic conditions and applies equally, for example, to patients who had a stroke. The fundamental issue for coverage under the standard clarified by Jimmo is whether the patient needs professional services to maintain function or to prevent or slow decline or deterioration.
The deciding factors are always whether the services are considered reasonable, effective treatments for the patient’s condition and require the skills of a therapist, or whether they can be safely and effectively carried out by non-skilled personnel.
Question: Does the Jimmo Settlement apply to patients who have dementia?
Answer: Yes. Dementia is not a disqualifying condition for Medicare coverage. If the patient needs skilled therapy to maintain the patient’s current condition or to prevent or slow the patient’s decline or deterioration, Medicare covers the therapy services, as long as all other coverage criteria are met. Skilled professional therapists are trained to work with patients who have dementia.
So, as the weather begins to warm over the coming month, and as we all look forward to longer days and the beauty of spring, let us remember that not all those we serve will “spring” through goals and progress. There are still those patients residing in the communities who still need us just to maintain.
Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at [email protected].
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
