SeniorTruth

Question: My husband broke his hip. He’s had surgery and has been in a nursing home for a week receiving physical therapy. Medicare has been paying so far, but the nursing home says he’s not improving, so Medicare and the therapy will stop. What can I do?

Answer: He should be able to keep receiving therapy and Medicare.

Background
Regularly, we hear that a nursing home has stopped providing therapy – giving the reason that Medicare will not pay the costs of therapy if the resident is “not improving” or has reached a “plateau.” When a nursing home gives this reason, it is wrong! Legally, lack of improvement is not a reason for stopping therapy or Medicare.

Must the nursing home provide therapy?
If the nursing home accepts Medicare, it must follow the Federal nursing home laws. Under those laws, the nursing home must provide the care and services that a resident needs to reach his or her highest practicable level of well-being. Therapy should be provided if the therapy improves the resident’s condition, or helps keep the resident’s abilities from diminishing.

So, if the therapy will at least help keep your husband’s abilities from diminishing, the nursing home is required to provide it. This is without regard to how the therapy is being paid for.

Must Medicare pay for it?
Medicare will pay costs of skilled rehabilitation services received in a nursing home. This includes services that require the skills of physical therapists, occupational therapists or speech pathologists. In fact, Medicare will pay the whole nursing home bill (not just the costs of therapy). Payment, however, is subject to Medicare’s limits on numbers of days covered in a nursing home. For the first 20 days Medicare pays 100%; for days 21 to 100 Medicare pays the amount due above a $128 per day deductible (some HMOs and insurance policies will pay the deductible). After 100 days, Medicare stops any payment.

The pertinent Medicare regulation clearly states that improvement is not necessary: “Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.”

So, if therapy will help prevent deterioration or preserve capabilities, Medicare will pay for it (within its limits on numbers of days).

Tips
When a nursing home tells you that it will stop providing therapy to a resident who is “not improving” or “not improving enough” you can take the following steps:

• Inform the nursing home about the content of this article – give them a copy if you like.
• Have the doctor confirm his or her order prescribing nursing home “skilled rehabilitation services.”
• Work with the therapists, and show that the resident is cooperating and that the therapy is helping the resident not to decline (or even to improve).
• If the nursing home persists and stops Medicare, demand that the therapy continue and an official Notice of Non-Coverage. Check the appeal box on the Notice, indicating that you want to appeal to the Medicare “intermediary.”
• If the intermediary rules against payment for therapy, further appeals are available.

A caution here: if your husband refuses to accept therapy, or is too confused to cooperate, the nursing home is within its rights to stop the therapy.

Additional resources
The best concise consumer guide on nursing home problems is 20 Common Nursing Home Problems from the National Senior Citizens Law Center – visit www.nsclc.org or call (202) 289-6976 ext. 201. For help with resolving problems at a nursing home in Los Angeles County, contact the Long-Term Care Ombudsman’s office toll free at (800) 334-9473. For the Ombudsman’s office in a different California county, check the CA Department of Aging site’s telephone list.