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My MIL is in an assisted living facility - she had a stroke in February - she is currently on Medicaid. She has been receiving physical therapy up until recently to help her get stronger and back to being able to walk, etc. - she currently uses a wheelchair but has been slowly progressing to where she can use a walker. I was just informed that her insurance will no longer pay for therapy as they have paid out the max they will allow. Without continued therapy, all of her progress will be lost and she is anxious to get better - she calls me constantly asking about this. Any ideas, suggestions would be appreciated. She DOES NOT have the funds to pay for outside therapy.

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Have you actually spoken 1-2-1 with the PT &/or OT?

I’d suggest that you do this ASAP. Medicare has rehab as a covered benefit, whether it’s post hospitalization rehab in a facility or community based (which if she’s in AL it might be this).
But how & if it’s paid depends on
- “progressing”, she has to be meeting certain markers and this is written up in her health chart likely daily or every other day as to just what her progress is.
- “bundling of care”, what Medicare & the other insurers do now is place a $ cap on rehab care. If part of this has been paid by her secondary insurance, they will follow whatever Medicare does.... so if Medicare has 86’d care then they will also. The facility or the therapist gets a set amount for a total bundle of services. So if she uses it all up in 3 weeks, that’s it.

As she’s had a stroke, there was a care plan done for her and within it will be a listing on her ICD-10 codes. These codes have an established followup to happen & that insurers will pay for. And the insurance has prenegotiated what will be paid based on the codes. Not a lot of flexibility once codes are in her chart in my experience.

The PTs & OTs are pros and know how to judge these two and run therapy so that they dovetail. If your mom is no longer “progressing” and used up the “bundle”, it’s going imho to be impossible to get more care. You can file an appeal, but if her chart shows no progress, the appeal is toast. Again speak with therapist ASAP.

Now she may be able to get “gait training”. Gait training or gait maintenance is kinda standard for those in a NH (skilled level of care place). It’s not “rehab” per se, but usually twice a week 1-1 work with the Pt or OT or therapy assistant / aide on walking and keeping muscle strength & it’s in the part of the facility where rehab has all their equipment set up. Medicare and Medicaid will pay for this. My mom had this 2- 3 times a week in both the NH she was in. The issue will be probably for y’all is that she’s in AL so there's not a big fixed Rehab section with staff and equipment.

Really you’ll find the OT or PT can better explain what all this means for possibly getting more care for your mom. It may be that she will need an assessment done to see if she is better off in a higher level of care facility, like a NH, that has therapy staff & equipment so she can get gait work 2-3 times a week.
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disgustedtoo Jul 2020
I was also going to suggest talking with the provider. Sometimes there are a max # of sessions, other times it may be the person has hit a "plateau" and is not progressing. Either will end the sessions.

Given the mom has dementia listed, it could be plateau. Our mother is in MC, and following some knee pain, they came in and worked with her. I'm sure mom didn't work on the exercises between visits, but at least she worked with them. Much later, about maybe 8 months ago, she started refusing to stand or walk unassisted (she was already using a rollator.) Partly fear of falling, partly becoming weaker from not walking and being overweight to boot. Anyway, PT came in and tried various ways to get mom to work with them. Nope. She flat out refused, and with the last attempt told them THEY should do what she was being asked to do.

I did have to sign the discharge paperwork and had to laugh at the "goals achieved" statement on it! Goals? Mom's goals maybe, but not the PT. So, it isn't always a number that is hit, though it can be. There are several reasons why PT may end and you need to know what it is. If it is a number, usually that renews the next year, but obviously that is 6m away.

Given her dementia, would any PT/OT help much? Mom may think it is, but perhaps she just likes the companionship. Would it be possible to get some instructions from PT and maybe hire a less expensive aide to walk with her? Just getting up and walking, even with a walker, will help strengthen her - a little more each day. An aide would be much less expensive than PT, if you have to self pay. Certainly can't hurt to try - if you can find a place that will do 1 hr/day, she can walk a bit, rest, walk a bit, etc for that hour, hopefully increasing the walk and reducing the rest.
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Insurance, I am assuming Medicare. Yes, there is a limit. I think she maybe able to continue with Medicare after so many days or months. Are you near Mom? Where you present when she was having therapy? Maybe the therapist can give you exercises that can be done daily to keep her strength up. Don't expect staff to do this. Unless you pay for the service.

If Mom means she wants to get back to normal, that may not happen. Her walker maybe as far as she gets. I would question if its she got to the max or did she hit a plateau and Medicare will not pay. If the later, Mom is as far as she will get. It really comes down to her doing for herself. She knows what exercises they did. Walking with the walker will help strengthen her.
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worriedinCali Jul 2020
Why are you assuming it’s Medicare when the very first sentence of the post says she’s on Medicaid?
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I've seen this play out. Insurance company maxes out and won't pay for any more therapy unless there's a change in the person's condition is what we have been repeatedly told. We were also told that elder should have "learned enough" in therapy to continue the exercises/routines on her own. In our case, this was a joke. Elder would not do anything "on her own" and anything she did do on her own was not in accordance with what she'd been taught in therapy. I can only speculate if she would be any better today with more therapy - because it would have ended eventually. I've been told no insurance plan pays for indefinite therapy. My elder also called constantly asking why she's not getting therapy and how will she "move out" of nursing home (she somehow decided she was only there to rehab and would be leaving once SHE decided she'd had enough therapy - which was going to be never because she liked the attention). Anyway, she does get up and moving with the staff as part of her routine care but it's not formal physical therapy - unless her condition happens to change or she comes up with a new complaint (which she has done a few times).
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You don't say what insurance is involved here. If it is traditional Medicare (the red, white and blue card) they will pay in full for the first 20 days (after a 3 night hospital stay) of rehab. If the patient needs more rehab after that, Medicare will pay for 80% of rehab services and you or your supplement insurance will pay the balance up to 80 more days. It's gets more complicated in the person goes into hospital for the same complaint within 60 days. Example: you are admitted to hospital and stay 3 nights and then go to a rehab facility for 7 days. 100-7=93 days of rehab available. But then you go back to hospital for the same complaint and get discharged to a rehab facility and get 14 days of rehab:
93-14= 79 days of rehab available.
The caveat on all of this is that the patient must be actively participating in the rehab program and the therapists must feel that they can continue to improve. Once they plateau, Medicare will not pay anymore.

If you have a Medicare Advantage insurance the length of time they will pay for rehab services is dependent on the contract of the covering insurance company. Even with this type of program the patient must be actively participating in the rehab program and the therapists must feel that they can continue to improve. Once they plateau, the insurance will not pay any more.

It will take 60 calendar days for the rehab clock to reset .

Now there are some LTC/HN that will help a resident with maintenance of physical activities by walking with them when they go to meals or activities or rolling a ball to them when they are doing table activities but this depends on the individual LTC and remember the CMA or CNA is not a trained (and therefore not a highly paid) therapist. I think the chance of finding this same service in an AL is rather remote because by definition the AL is only set up to provide an "assist" to the activities of daily living (ADL) although many have established MC units that are more fully staffed but not necessarily with qualified nursing (CNA/CMA) staff. Anything more than that falls under the auspices of the LTC
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worriedinCali Jul 2020
The very first sentence of the post says that the OPs MIL is on Medicaid and in assisted living. She’s not in rehab.
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I also observed my elder being non-compliant with therapy on multiple occasions and those instances don't help either. And then she cried a river when there was no more therapy. Seems that unless there is a legit reason not to cooperate on a particular day, elder MUST do as they are told or it will likely be recorded as a refusal of therapy and insurance companies don't like that. I watched as elder requested to be put in a hospital gown (didn't even want her own clothing) and said she would do therapy tomorrow as she was "too tired" today. So, she was too unwell to take full advantage of the therapy being offered but she's too "well" to live in a facility. Of course, this is all according to HER. Obviously, this is not the situation in every case, but elders need to make sure they aren't creating the impression that they are not working hard at therapy. It also didn't help that my elder thought she had 4 months in rehab, so it's easy to do something "tomorrow" when you think you're going to be there for months. She was sent home in a matter of weeks and nowhere near ready.
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igloo572 Jul 2020
Likely gets written up as “NCC” noncompliant for care in thier chart. Once that happens 3 consecutive times, and it’s in the chart, Medicare will stop payment. Once stuff hits like this hits their charts, they are toast on getting an appeal done in their favor in my experience.

PT & OT aren’t gonna beg and cajole them to get up and participate. Either MeMaw gets with the system or gets NCC’d & rehab stopped. Sometimes family can cheerlead enough to get them motivated but if not and they flat won’t do rehab, it’s over.
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This is such a familiar conversation. My mother had a stroke in November. She's in a wheelchair. She used up her Medicare 100 days rehab and was discharged from the rehab facility 3.5 months ago. Since then, she's gone through her 100 allotted days of Medicare-covered, in-home therapy services during which she began to stand up at a walker and take some steps - something she had not been encouraged to do at all due to her weakness, loss of cognitive function and assumptions that she would not be using her left leg ever again while in the rehab. As her progress at home has been really good, but slow, we wanted to keep going somehow after this second Medicare discharge. We couldn't appeal because of her lack of speed, motivation and "need". I guess. She could then be prescribed outpatient services which would mean taking her to a facility for PT and OT which was problematic because of covid and how the effort of getting her there would be exhausting in and of itself. So we talked to her doctor about our concerns and she found an agency that bills as outpatient, but does in-home care through Medicare part B. Apparently, these services will be given indefinitely. They are much better therapists than the ones who knew they only had 100 days to accomplish something, although to their credit they did get her up into the walker, and my mother's stands are improving. I just wish she'd get a better attitude about her progress. She's just so negative about herself. It would go a long way to help her accomplish her goal of getting to use the bathroom by herself if she'd work on decreasing her negativeself-talk but it's so entrenched overher entire lifetimeof 88 years, far longer than the effects of the stroke.. I fear that is the hardest part of this whole thing. The body is one thing, but the mind is quite another. Anyway, for what it's worth, check into therapy services that can go into AL as "outpatient " and bill part B for those services.
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Ricky6 Jul 2020
Great idea for Hirshy1230, but be advised there will be limit for how many days will be covered by approved outpatient services as well. If there Is rehab center nearby you could also look into joining their outpatient fitness center. They usually will have trainers that will work with you on per diem basis for a fee.
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Too many people here seem to be confusing "answers" with the original poster's question.

The OP is on MEDICAID and resides in an Assisted Living facility.

Please scroll ALL the way to the top, to see the ORIGINAL QUESTION, posted by "Hirshy 1230."
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If she is on Medicare they have a certain amount they cover and the people doing therapy and her Doctor must provide documentation it is needed to continue as long as she is making progress. If she has reached the maximum level of ability and not expected to make any further progress they stop coverage. Possibly they think she has reached her maximum and she won’t progress any further?
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Screennamed Jul 2020
Facilities are paid a (per diem) daily rate that includes PT+OT.

BTW, That "Not making progress," excuse was eliminated in 2013 (Jimmo v. Sebelius).

NOW Medicare + Medicaid are telling stroke survivors to argue with that facility for PT + OT, to maintain that resident's physical and psychological well-being.

If any therapist tries to utilize the "Not Making Progress," FIGHT against that "not making progress," bullsh*t
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Check with her "insurance," Medicaid directly.
Our facility always terminates physical therapy and occupational therapy for Medicaid + Medicare stroke survivors, (always 5 weeks b/4 their Medicaid "re-certification").Even though CMS pays for PT+OT within their (per diem) daily rate $$$ paid to the facility.

(Medicare/Medicaid) CMS has repeatedly stated individually each of our denied residents/patients arere still eligible for PT + OT. BUT our facility continues to deny in-house services, to all CMS stroke survivors

OFF-SITE-->SOLUTION
(Medicaid/Medicare) CMS will pay for off-site therapies. Talk to Medicaid/Medicare about Off-site PT+OT at an outside physical therapy place.

At our facility Each (who was denied therapies) obtained PT and OT off-site, fully covered by CMS. (Medicaid/Medicare),
______________________________________

BUT our in-house therapy office will block new prescriptions for off-site therapies. by telling neurologist that the resident isn't "making progress" or has reached a plateau. Sidebar: "Not Making Progress," is an old outdated excuse overturned, ejected out of the vernacular of CMS (2013 Jimmo vs. Sebelius). But many still incorrectly utilize it.

WHY is our corporation blocking therapy? Perhaps ...Money has been the reason for terminating therapies. Each therapy is terminated for different false excuses. The list of excuses is filled with inaccurate statements (outright lies). That were documented by various agencies as being inaccurate.

I watched a former administrator block a resident from obtaining transportation to an off-site PT/OT place.That administrator stood by the front blocking access to transportation. It was bizarre.
__________________________________________
All in all

1. contact that "insurance" Medicaid CMS directly. Learn how that facility is paid and what that payment includes. And the duration of a stroke survivor's therapies
After you have clarified DIRECTLY with the "insurance," the status of PT + OT.
(sidebar: PT +OT for stroke survivors is normally ongoing).
2. Find out where Medicare/Medicaid will pay-for her PT/OT off-site LOCATE/FIND that Off-site PT+OT at a physical therapy place
contact the off-site facility, schedule an appointment, arrange transportation or bring her to that off-site location.

I'm expecting you to learn exactly what each of our residents learned, that your mother is still eligible for PT +OT, Talk with her Neurologist to get him to write an ongoing PT +OT prescription.
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Medicare usually pays for Therapy.
Did the days max out, or did therapy not
re-certify her to continue therapy?
Maybe ask the social worker if there is one
at the assisted living office, or call local agency
on aging to see what resources they may
suggest.
Otherwise this may be where family and friends
need to step in and help her with therapy exercises
if possible. It's not the same as a professional, but
certainly better than no therapy, no exercises.
Ask her current therapists for instructions (they
usually have the standard pre-printed ones).
Use those, even if you are only there 1 or 2 days
a week and no one else can help out, that is
better than zero days a week.
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