Medicare Therapy Rules Made Easy

Most of us take for granted that we can get out of bed in the morning and do all the things necessary to head out and face our day. You know… the simple everyday things like moving around our house, showering, getting dressed and eating breakfast. I might be a little foggy most mornings but I don’t think about whether I’ll face an enormous challenge in measuring out the coffee or pouring the milk. The point is the routine is just that…routine.

But if your parent is frail, you know that there’s nothing routine about these activities — that for them, doing even the simplest things just can’t be taken for granted anymore.

The mobility and functioning that’s essential to independence and safety suddenly becomes a big effort. And, Daughterhood really happens when we have to get involved in helping our parents do the things that they can no longer do by themselves. This is when their lives and ours get hard.

That’s why, from a daughter’s perspective, you want to be super invested in anything that can help maintain or restore your parents’ ability to handle daily tasks independently and to get around on their own.

And the most useful tools in the independence toolbox for older adults are the three therapies:
physical, occupational, and speech/language. These therapies, working together, can help your parent continue doing all the usual things they normally do – or help them get back to doing these things after an accident or surgery.

Read: A Go-To Guide for Understanding Your Parents’ Rehabilitation

Unfortunately, the Medicare rules around how and where your parent can get therapy are incredibly COMPLICATED! As part of our series on therapy and functioning at home, I’m going to boil it down for you here.

The thing to remember is that Medicare pays for therapy through four main service pathways. Two of these pathways are for post-hospital care only and the other two are available regardless of whether your parent has recently been in a hospital.

Here’s how each pathway works.

Therapy in a Skilled Nursing Facility

What many people don’t realize is that most nursing homes do double duty as places where people live when they can’t take care of themselves anymore AND as facilities for short-term rehabilitation therapy following a hospitalization. These days, the majority of frail older adults who need intensive rehabilitation therapy after a hospital stay receive it in a nursing home – referred to as a “skilled nursing facility” – where they’ll stay for about three weeks before going home.

Medicare-covered skilled nursing facility care may provide any or all types of therapy as well as the nursing and other clinical care your parent might need before going home. It’s pretty typical for an older adult who has had knee or hip replacement, or is recovering from a hip fracture, to receive therapy in a skilled nursing facility following hospitalization.

Read: The 3 Surprising Medicare Benefits You MUST Know About

If your mom or dad spends more than three nights as an inpatient in a regular hospital, and has a need for skilled care, Medicare will cover 100% of the costs for the first 20 days of care in a skilled nursing facility. After 20 days, there’s a 20% copayment that can be covered by Medigap, Medicaid or out of pocket.

It’s important to note that Medicare pays skilled nursing facilities by the day, like a hotel, which means that most facilities aren’t in a big hurry to discharge your parent. And, the more therapy your parent gets, the more money per day the facility gets. I’ve had quite a few people tell me that they feel their parents are getting TOO much therapy and that’s entirely possible. Remember, it’s well within your rights to question how much is being provided.

Therapy in an Inpatient Rehabilitation Facility

In some cases, your parent may be discharged to something called an “inpatient rehabilitation facility” which – from a daughter’s perspective — could easily seem indistinguishable from a skilled nursing facility.

However, inpatient rehab is usually a more intense place than a skilled nursing facility. These facilities are licensed and paid as hospitals and can be great for a younger person who’s recovering from an automobile accident or a traumatic brain injury (think Gabby Giffords).

For the purposes of Medicare coverage rules, all of the normal hospital copayments and deductibles apply here. These facilities get paid a lump sum for the whole stay just like regular hospitals.. So, in contrast to the skilled nursing facilities, they’re going to be working a lot harder to discharge your parent quickly.

If you ask me whether your parent should be in an inpatient rehab facility or a skilled nursing facility, I’d have to honestly say that, for most frail older adults, a really good skilled nursing facility is a less expensive and more appropriate place for recovering from a hospital stay.

But, what makes all this even more complicated is that quality varies tremendously between and across both types of facilities. And, sadly, much of the time the hospital’s making a decision that has very little to do with what’s best for your mom or dad and everything to do with getting them out of their hair as quickly as possible.

Read: 5 Safety-First Strategies for Your Parent’s Hospital Discharge

Therapy from a Home Health Agency

At some point, either right after a hospitalization or after a stint in the skilled nursing facility, your mom or dad is going home…..still needing therapy and nursing care but too fragile to get out of the house easily. In this case, Medicare will pay for a limited amount of “home health” care, which is really mostly rehabilitation therapy at home.

I think one of the best things about “home health” care is the opportunity to have an occupational therapist on site helping your parent relearn how to interact with his or her home environment. Home health is not restricted to post-hospital care and is available anytime as long as your parent meets the fairly strict criteria for needing it.

To qualify for the benefit though, a doctor must certify your parent needs it… AND, that doctor must actually have seen your parent, in person, sometime within the last 90 days to verify the need for home health.

You can see the irony here… that your parent has to be so frail that it’s not reasonable to expect him or her to leave the house and yet, somehow has to get to the doctor to get certified for needing home health. Argh.

Watch: Daughterhood Voices – When Answers Are Hard to Find

But, once you get your parent certified, there are no copayments or deductibles. So that’s something!

Outpatient Therapy

If your parent has Medicare Part A (hospital) coverage, which most people have, or if your parent is enrolled in a Medicare Advantage plan, all of the three pathways mentioned above are available to you.

If your parent has Medicare Part B (or is enrolled in a Medicare Advantage health plan), he or she may also qualify for outpatient therapy services, which are very similar to the therapy you and I are familiar with – where you go to a therapy center and work with a therapist.

Because this is Part B, if your parent is traditional Medicare Part B (as opposed to a Medicare Advantage plan), there’s a 20 percent copayment and the Medicare Part B deductible applies. That’s pretty straightforward.

What’s not straightforward is that there are limits to how much therapy’s reimbursable under the Part B outpatient therapy benefit. Generally, your parent can get $1,960 worth of combined physical therapy and speech/language therapy and $1,960 worth of occupational therapy without any problems or questions. And if the therapist can substantiate an ongoing need, your parent may qualify for another $1,740 worth of therapy in each category through something called an “exceptions process.” But that’s not guaranteed.

Phew. Who thought this all up?

Therapy When Your Parent Lives in Assisted Living or a Nursing Home

Things can get pretty murky when your parent is living long-term in assisted living or a nursing home – in terms of the service category under which Medicare will pay for therapy. I’ve created the handy little table below – just so you know what’s what when your mom or dad lives somewhere other than a typical home.

Medicare C2

Bottom line: This is a huge mess. Medicare is a conglomeration of benefits tacked on and revised piecemeal over time, with more of an eye towards cost control than what will work best for the families who have to navigate it. So, best of luck because you’ll need it and let me know your experiences in the comments section!