Maintaining functional abilities is crucial for individuals in long term care settings. Medicare plays a significant role in covering services that help maintain these functions. This article clarifies the scope of Medicare coverage for functional maintenance programs, emphasizing the necessity of skilled therapy and medical justification.
Defining Skilled Maintenance Therapy Under Medicare
Medicare recognizes the importance of skilled maintenance therapy when it is essential to maintain a patient’s current functional level or to prevent or slow down further decline. This coverage extends beyond just restorative therapy, acknowledging that ongoing interventions are often necessary for individuals with chronic conditions or those in long term care. The key factor determining Medicare coverage is whether the maintenance program requires the expertise and skills of a qualified therapist, such as a physical therapist (PT) or a physical therapist assistant (PTA).
This need for skilled intervention is not dictated by a specific diagnosis or condition but is patient-specific. It hinges on an individualized assessment that justifies the need for skilled care to ensure the maintenance program is both safe and effective. For instance, even with a chronic condition like Parkinson’s disease, a therapist can develop a maintenance program directly from an initial evaluation, without requiring prior restorative therapy, if the documentation clearly supports the necessity for skilled therapy to maintain function or slow deterioration. Continuous skilled maintenance therapy is covered when the required therapeutic procedures are complex and necessitate a high level of therapist expertise.
Medical Necessity: The Cornerstone of Medicare Coverage
Like all services covered by Medicare, skilled maintenance programs must meet the criteria for medical necessity. This means the services must be deemed reasonable and necessary, requiring the unique skills of a physical therapist to be justified for coverage. The establishment of a maintenance program itself, along with the instruction and training provided to patients and caregivers for its implementation, falls under medical necessity when a therapist’s skills are required. Furthermore, the periodic assessment of the program’s effectiveness and the need for modifications also contribute to meeting this requirement, again, when the skills of a therapist are essential.
Who Can Deliver Skilled Maintenance Services?
Medicare Part A and Part B both allow for qualified professionals to provide maintenance therapy services.
Part A Settings (Home Health and Skilled Nursing Facilities – SNFs): In these settings, PTAs, under the supervision of a PT, are authorized to deliver both rehabilitative and skilled maintenance therapy. This is within the framework of a care plan established by a qualified therapist, adhering to state licensure laws and the therapy scope of practice. While PTAs can provide the services, the qualified therapist retains responsibility for the initial assessment, developing the plan of care, creating and modifying the maintenance program, and conducting reassessments.
Part B Settings (Outpatient, Home, Assisted and Independent Living Facilities, SNFs): Under Medicare Part B, both PTs and PTAs (since January 1, 2021) can provide rehabilitative and skilled maintenance therapy. This includes services delivered in various settings, expanding access to necessary care. It’s important to note the requirement for the CQ modifier when services are provided, either wholly or partially, by a PTA, as mandated by existing Medicare rules.
In conclusion, functional maintenance programs are a vital aspect of long term care, and Medicare coverage is available when these programs necessitate the skills of qualified therapists and meet medical necessity criteria. Understanding these guidelines ensures that patients receive the appropriate care to maintain their functional abilities and overall quality of life in long term care settings.
