Clarifying Medicare Guidelines

A look at how the new budget affects coverage

The controversy that surrounded PT, OT, and speech services seemed to be alleviated, once and for all, by February’s congressional budget agreement.

Of course, to remove all confusion we must understand what Congress approved, and how it differs from the previous standard.

Medical necessity. All therapy covered by Medicare must be deemed reasonable and necessary to treat the individual’s illness or injury, while requiring the services of skilled professionals.

Part A therapy services. If a Medicare recipient has an inpatient hospital stay of at least three days, he or she becomes eligible for up to 100 days of rehabilitation, including therapy, in a skilled nursing facility under Medicare Part A.

Therapy services covered by Medicare Part A also can be obtained in an inpatient, hospital-based rehabilitation facility. In this setting, requirements call for therapy to be “intensive”—at least three hours a day, five days a week. Stays are covered by Medicare up to a maximum 90 days.

Part B therapy services. PT, OT, and speech are now covered in outpatient clinics, private practices, and skilled nursing facilities once an individual has exhausted Part A services.

The end a 20-year battle over ‘therapy caps’—the annual limits Congress placed on Part B services back in the 1990s. For many rehab professionals, this stipulation was the highlight of the bill.

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