Medicare
Medicare confirms daily therapy alone can qualify a nursing facility stay
After a lawsuit by a Medicare advocacy group, federal officials told Medicare's appeals board that patients needing daily physical or occupational therapy can get skilled nursing facility coverage without daily nursing care.
Key facts
- CMS reversed an appeals decision that limited rehab coverage.
- Daily therapy alone can meet Medicare's skilled nursing facility test.
- The change came from a court settlement.
What happened
The Centers for Medicare & Medicaid Services sent a letter on October 26 directing the Medicare Appeals Council to throw out one of its own decisions. That decision had said Medicare could cover a skilled nursing facility stay after a hospitalization only if the patient needed daily skilled nursing, not just daily therapy.
The Center for Medicare Advocacy, which reported the letter on October 29, had taken the case to federal court in Connecticut on behalf of a man who received daily occupational therapy in a nursing facility. The case settled. CMS's letter says a person can qualify for the post-hospital benefit based solely on a daily need for medically necessary skilled rehabilitation, such as physical or occupational therapy.
What it means for families
Many older adults go to a nursing facility after a hospital stay mainly for rehab. This letter backs up their right to Medicare coverage when therapy, not nursing, is the main daily need.
Daily generally means five or more days a week of therapy.
The usual Medicare rules still apply, including a qualifying hospital stay and coverage limits.
Facilities and Medicare contractors sometimes end coverage when a patient's progress slows, so families should know the rules and ask questions before agreeing to a discharge date.
New York families whose parent is told rehab coverage is ending because they "only" need therapy can cite this clarification in an appeal.
What to do this week
- Ask for any coverage denial in writing.
- Appeal quickly if a facility says Medicare will stop paying for therapy.
- Mention the October 26 CMS letter to the facility or appeals contractor.
Sources
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