Are you being shortchanged by Medicare without even knowing it?

Oct 16

Written By

Maybe one of the most interesting things to surface recently pertaining to Medicare Coverage pertains to the improvement standard.

What is that you ask?

You or a loved one may be receiving Medicare-covered services like physical therapy (PT) or occupational therapy (OT). However, your health may have plateaued or improved such that you are “no longer improving” and therefore Medicare stops payment for the service and you stop receiving the service.

“Yikes,” you say because if you don’t continue with, for example PT, then your health may decline and possibly land you back in the hospital. You have the right to appeal.

Martin's story

Take Martin, an 80 something year old who was in the hospital due to a fall and then on to a nursing home for rehabilitation.

He transitioned back to his assisted living apartment with skilled home health following him, which involved Medicare-covered PT and OT. Martin did well with therapy but was told it would stop because he was no longer showing improvements . Within weeks of the therapy stopping, Martin’s functionality decreased to the point that he was needing a two person assist.

This could have prohibited him from remaining at the assisted living, until the assisted living manager learned of the Jimmo v. Sebelius case that resulted in Martin being able to continue receiving PT and hence, remaining in his apartment.

The Centers for Medicare & Medicaid remind providers that Medicare covers the therapy that Martin received because he is a beneficiary that needs such care in order to prevent or slow decline or maintain his functionality. This is referred to as a “maintenance coverage standard”.

What can you or a loved one do to try and prevent a lapse in care? Question your provider of Medicare covered services to discuss the potential continuation of such services.

Are you looking for housing options for yourself or a loved one? Explore our Intergenerational Housing program.