Understanding How Medicare Determines Payment for Your Therapy Services in Nursing Homes or Home Health Care
If you or your loved one is receiving physical therapy, occupational therapy, and/or speech-language pathology services in a nursing home, or if you are receiving care at home by a home health agency, you should be aware of some major changes that Medicare has made in the way your physical therapist, occupational therapist, or speech-language pathologist is paid for these services.
Therapy Services in Nursing Homes. On October 1, 2019, Medicare shifted to a new payment system called the Patient-Driven Payment Model for nursing homes, often referred to as skilled nursing facilities or SNFs.
Therapy Services at Home. On January 1, 2020, Medicare applied a similar payment change called the Patient-Driven Groupings Model for therapy services managed by home health agencies provided in your home.
Medicare implemented the payment changes to promote patient-focused care as the most appropriate way for it to pay for services. The new systems base care on the unique characteristics, needs, and goals of each patient, and they were supported as the most appropriate way to pay for services by the three national associations representing providers of these services: the American Physical Therapy Association, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association.
Unfortunately, some SNFs and home health agencies are using these new payment models to stint on care, which may put patients’ health at risk. Medicare requires that SNFs and home health agencies provide medically necessary physical therapy, occupational therapy, and speech-language pathology services, regardless of the diagnosis.
To protect your rights and ensure that you are receiving necessary therapy, you should be aware of the following common statements shared with patients receiving therapy that are not true.
- Your provider may state: Medicare limits the amount of therapy that beneficiaries can receive in SNFs and home health.
FACT: Medicare does not limit the amount of therapy you can receive in either of these settings, and the clinical judgment of your therapist should be a key factor in determining the amount of therapy you receive. However, many SNFs and home health agencies use computer programs that “predict” the amount of therapy a patient needs in order to dictate visits, without accounting for the clinical judgment of your treating therapist. They may use the results to require therapists to restrict the number of minutes spent per visit or the number of visits allowed. For example, you may be told that Medicare allows only 15-minute sessions or three home health visits. This simply is not true. Care decisions should be made by the interdisciplinary care team in consultation with patients, not computer algorithms.
- Your provider may state: Medicare dictates what forms of therapy a therapist can deliver. For example, you may be told that Medicare states that only occupational therapists or speech-language pathologists can deliver cognitive treatment.
FACT: Medicare defers to state law and the scope of practice of the treating clinician. For example, an occupational therapist and a speech-language pathologist could both address distinct traits of cognitive deficits within their respective scopes of practice as functionally necessary for the patient.
- Your provider may state: A portion of SNF therapy treatment must be provided in a group.
FACT: Medicare does not require patients in a SNF to receive group therapy. Group therapy may be clinically indicated for a patient, and Medicare allows up to 25% of the patient’s treatment to be provided in a group of two to six individuals and/or as concurrent therapy, meaning two individuals being treated at the same time, during the patient’s stay in the SNF. Medicare expects that the needs of the patient and the clinical judgment of the clinicians will drive decisions on the mix of individual, concurrent, and group therapy for the most effective therapeutic treatment. The clinician or SNF cannot and should not use group therapy to manage schedules or for their own convenience.
- Your provider may state: Medicare will only pay for therapy services designed to improve a patient’s condition.
FACT: Medicare will pay for services designed to improve or maintain function for the patient. Improvement or progress is not required, and Medicare must cover maintenance therapy when it’s medically appropriate. A 2013 legal settlement, Jimmo v. Sebelius, confirmed this.
- Your provider may state: Medicare does not pay for therapy for certain diagnoses.
FACT: Certain diagnoses or clinical conditions trigger additional payment for therapy above the clinical groups included in the SNF and home health payment models, but Medicare requires SNFs and home health agencies to provide all medically necessary services, including therapy services, to patients regardless of their diagnoses. For example, the Centers for Medicare & Medicaid Services, which oversees the Medicare program, has stated this about the home health Patient-Driven Groupings Model:
“While these clinical groups represent the primary reason for home health services during a 30-day period of care, this does not mean that they represent the only reason for home health services. While there are clinical groups where the primary reason for home health services is for therapy (for example, Musculoskeletal Rehabilitation) and other clinical groups where the primary reason for home health services is for nursing (for example, Complex Nursing Interventions), home health remains a multidisciplinary benefit and payment is bundled to cover all necessary home health services identified on the individualized home health plan of care.”
- Your provider may state: Medicare does not cover home health services unless the patient is discharged from the hospital, SNF, or other institutional setting.
FACT: Under the home health payment system, Medicare pays a different amount depending on where the patient was before being admitted for home care. Regardless, patients are eligible for home health no matter where they had been before being admitted to home health and starting an episode of care.
- Your provider may state: Medicare won’t pay for home health care services after 30 days.
FACT: While the cycle of payment for a period of care has changed from 60 days to 30, Medicare does cover services that continue beyond 30 days when they are medically necessary. Payment for 30-day cycles after the first 30 days is less, though, so some home health agencies may inappropriately discharge patients within the first 30 days to avoid the lower payment of the next 30-day billing cycle.
If you think your SNF or HHA has inappropriately restricted access to therapy services, you have options to get help.
- Ask your physician to help you get the care they ordered, you need, and are entitled to receive.
- Register a complaint with the SNF or home health agency compliance officer, manager, or staff. In most states, you can file SNF complaints with state ombudsman offices, and home health agency complaints with state survey and certification agencies.
- Contact Medicare at 1-800-Medicare (1-800-633-4227).
- Reach out to a consumer advocacy group to share your story and get help obtaining your medically necessary care:
- Center for Medicare Advocacy: provides education, advocacy, and legal assistance to help older people and people with disabilities get quality health care from Medicare.
- Medicare Rights Center: helps people with Medicare understand their rights and benefits, navigate the Medicare system, and get the quality health care they deserve.
- Senior Medicare Patrol: helps Medicare beneficiaries, their families, and caregivers prevent, detect, and report health care fraud, errors, and abuse through outreach, counseling, and education.
- Local Area Agency on Aging: links those who need help with state and local agencies on aging and with community-based organizations that serve older adults and their caregivers.
- Find out about your rights to appeal if you receive an advanced beneficiary notice, sometimes called an ABN, from the SNF or home health agency indicating a denial or stop of service. The Centers for Medicare & Medicaid Services has information.
- Consider seeking services from a different SNF or home health agency, if you can.