You hear it all the time: “Medicare will only pay for rehab or personal care as long as you are getting better. If you are no longer improving after, say, a stroke, these benefits will stop.”
But according to the Center for Medicare Advocacy, a non-profit patient’s rights group, this “improvement standard” may have become ingrained in the care system, but it has no legal basis. “It is” says Vicki Gottlich, a senior attorney with the center, “an urban myth.”
The center argues that Medicare must continue to pay for care as long as a patient needs skilled services to maintain their health status. In other words, Medicare should continue to pay for treatment as long as a doctor certifies it will prevent you from getting worse or even help you maintain your functional abilities, not just because it will help you get better.
There is no doubt this improvement requirement is hard-wired among providers such as home care agencies or nursing homes. Even advice columns get it wrong. Here is a typical one. Agencies tell clients all the time that they can no longer provide physical therapy or an aide to help with bathing or dressing because Medicare won’t pay any more. If you want that extra care, they say, you’ll have to pay for it out of your own pocket. Similarly, nursing homes will stop physical therapy once a physician no longer certifies you are improving. “Medicare won’t pay anymore,” they will tell you. Once again, they’ll say you can still get therapy, but you’ll have to pay yourself, and few can afford it.
Oddly, Gottlich says the Medicare law and even the regulations “are pretty clear.” But, somehow, over the years, providers have come to believe that Medicare will cut off patients who are not showing improvement.
The center is now embarking on a full-blown effort to get Medicare to clarify its rules and make clear to home health agencies and skilled nuring facilites that it will indeed pay for services a patient needs to maintain health status.
One warning: Even a Medicare clarification won’t help if your care is paid by private insurance. Individual policies have their own standards for when they will pay for rehab or home health care, and there is nothing to prevent them from limiting benefits only to those who are improving. So, the usual rules apply: When you buy private insurance, read the fine print.