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While the Medicare Act covers physical, speech, and occupational therapies in various community-based and facility settings, coverage is often denied or inappropriately limited. 

Most often, this is because the individual requires therapy to maintain her condition, or slow deterioration. When an individual is not going to improve, providers too often decline to provide therapy or discontinue services, believing Medicare will not cover “maintenance therapy.” While this has never been legally correct, Medicare claim administrators have reinforced the belief for years with incorrect coverage guidelines and frequent claim denials. 

In January 2013, a national class action lawsuit that challenged Medicare denials for lack of improvement was settled in a federal court case, Jimmo v. Sebelius. The Jimmo Settlement makes it clear that Medicare is equally available for skilled therapy that is needed to maintain an individual’s condition, or slow deterioration, as it is for therapy that will improve the condition. This is particularly important for people with long-term conditions, illnesses, and injuries – such as Parkinson’s disease, Multiple Sclerosis, stroke, spinal cord Injuries, brain injuries, and ALS.  

Despite the Jimmo Settlement, which is the law of the land, people are still regularly denied Medicare and access to necessary therapy when they cease to improve, have an underlying condition from which they won’t improve, or do not improve within a particular period of time.  Medicare Contractors need to address this inequity by properly covering claims for skilled maintenance therapies. CMS needs to monitor their Contractors’ behavior to ensure beneficiaries have fair access to Medicare and necessary care.

In addition to this ongoing problem, outpatient therapies are subject to a $1,940 annual Medicare payment cap. While exceptions to this cap are available, providers often will not continue beyond the $1,940 mark because of “the hassle” and for fear of being audited. This annual payment limit creates significant barriers to necessary therapy for people with ongoing conditions and injuries.

When we think about proper coverage for therapy and its value for people with devastating conditions, we should think about former Congresswoman Gabby Giffords, who was catastrophically injured in a shooting. Fortunately, because of years of therapy, she is now walking and talking. Everyone deserves the same opportunity if they are injured or ill.

Medicare law supports coverage for therapy to improve and maintain an individual’s condition. Medicare providers should provide the therapy, Medicare Contractors should cover the claims, and Congress should eliminate the arbitrary cap on outpatient physical, speech, and occupational therapies.

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