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 language pathology services in a nursing home or at home by a home health agency, you should be aware your rights. You also should know about some major changes that Medicare has made to how your therapist gets paid.
Therapy Services in Nursing Homes
On Oct. 1, 2019, Medicare moved to a new payment system for nursing homes (also called skilled nursing facilities or SNFs). It is called the Patient-Driven Payment Model.
Therapy Services at Home
On Jan. 1, 2020, Medicare began using a new payment system for home health agencies. It is called the Patient-Driven Groupings Model. It addresses therapy services managed by home health agencies provided in your home.
Medicare made these payment changes to promote patient-focused care. The new systems base payment on each patient’s specific needs and goals. These organizations support the new systems as the most appropriate way to pay for therapy services:
- American Physical Therapy Association.
- American Occupational Therapy Association.
- American Speech-Language-Hearing Association.
These national organizations represent the providers of therapy services.
Unfortunately, some SNFs and home health agencies are using the new payment models to provide less care than is necessary. This 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. This is true no matter what the diagnosis.
Protect your rights. Make sure that you receive the proper amount of necessary therapy; be aware of these common false statements:
- You may be told: Medicare limits the amount of therapy that you can receive in SNFs and home health.
FACT: Medicare does not limit the amount of therapy you can receive in either of these settings. The clinical judgment of your therapist should be a key factor to determine the amount of therapy you get. However, many SNFs and home health agencies use computer software to “predict” how much therapy a patient “needs.” These programs set the number of visits, without considering the clinical judgment of your treating therapist. They may use the results to limit the number of visits or minutes allowed per visit. For example, you may be told that Medicare allows only 15-minute sessions or home health visits. This simply is not true. Care decisions should be made together by the members of your health care team and you, not a computer program.
- You may be told: Medicare governs what forms of therapy a therapist can give. For example, the facility or home health agency may tell you that only occupational therapists or only speech-language pathologists can provide cognitive treatment.
FACT: Medicare defers to state law and the scope of practice of the treating health care professional. Scope of practice means the services a health care provider is permitted to give in the state where they practice, in keeping with the terms of their professional license, education, experience, and skill. For example, an occupational therapist and a speech-language pathologist can both address cognitive problems within their scopes of practice as necessary for the patient’s function.
- You may be told: A portion of SNF therapy treatment must be done in group therapy.
FACT: Medicare does not require patients in SNFs to receive group therapy. Group therapy may, however, be right for a patient. Medicare allows up to 25% of a patient’s treatment during their stay in an SNF to be provided in a group of two to six people. It also can be provided as concurrent therapy, meaning two people are treated at the same time. Medicare expects that a patient’s needs and the provider’s clinical judgment as to the most effective treatment will drive decisions on the mix of:
- Individual therapy.
- Concurrent therapy.
- Group therapy.
The clinician or SNF cannot and should not use group therapy to manage schedules or for their own convenience.
- You may be told: Medicare only pays for therapy services designed to improve a patient’s condition.
FACT: Medicare will pay for services designed to improve or maintain function. Improvement or progress is not required. Medicare must cover maintenance therapy when it is medically appropriate.
- You may be told: Medicare does not pay for therapy for certain diagnoses (conditions).
FACT: Medicare requires SNFs and home health agencies to provide all medically necessary services to patients regardless of their diagnosis.
- You may be told: Medicare does not cover home health services unless the patient is discharged from a hospital, SNF, or other facility.
FACT: Under the home health payment system, Medicare pays a different amount based on where the patient was before admission to home care. Patients are eligible for home health no matter where they were before admission to home health.
- You may be told: Medicare won’t pay for home health care services after 30 days.
FACT: The cycle of payment for a period of care has changed from 60 to 30 days. However, Medicare does cover medically necessary services that continue past 30 days. Payment for after the first 30-day cycle is less, though. Some home health agencies may improperly discharge patients within the first 30 days. This is an attempt to avoid the lower payment for the next 30-day billing cycle.
If you think your SNF or home health agency has wrongly limited your access to therapy services, here are options to get help.
- Ask your doctor 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. Home health agency complaints can be filed with state survey and certification agencies.
- Contact Medicare at 800-Medicare (800-633-4227).
- Reach out to a consumer advocacy group to share your story. These groups can help you obtain medically necessary care:
- Center for Medicare Advocacy. Provides education, advocacy, and legal assistance. They help older adults and people with disabilities get quality health care through Medicare.
- Medicare Rights Center. Helps people with Medicare understand their rights and benefits under Medicare. The center works to help you get the quality health care you deserve.
- Senior Medicare Patrol. Helps Medicare beneficiaries, their families, and caregivers prevent, detect, and report health care fraud, errors, and abuse. They do outreach and provide counseling and education.
- Local Area Agency on Aging. Links people who need help with their state and local agencies on aging. They also can refer you to community organizations that serve older adults and their caregivers.
- Find out about your rights to appeal an advanced beneficiary notice, or ABN, from the SNF or home health agency if you receive a denial or stop of service. The Centers for Medicare & Medicaid Services offers this information.
- Consider seeking services from a different SNF or home health agency if you can.