Medicare Maintenance Care: Who Qualifies For What Services

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Does Medicare cover maintenance care?

Medicare covers maintenance care for patients who qualify under CMS guidelines of requiring skilled care in a homebound status, in a hospital, an outpatient rehab setting, or a skilled nursing facility without needing documentation of improvement.

Medicare Maintenance Care explained by Medicare

In the past, CMS mandated that services provided to a patient had to show ongoing patient improvement for benefits to continue, otherwise the patient had to be discharged from skilled care regardless of the setting in which the services were being delivered.

CMS was sued in 2011 (Jimmo vs Sebelius) stating that patients unable to show continual improvement in home health, outpatient, and nursing facility settings were discriminated against. Subsequently in 2012, the case settled in favor of the patient, setting a precedent to deliver skilled services to patients, regardless of the patient’s inability to show progress.

The skilled services of Physical Therapy, Occupational Therapy, and Speech Therapy may be provided as long as clear documentation of orders and therapy notes document a skilled need and instruction is provided at each visit.
The criteria for providing maintenance care is largely dependent on the skilled services documentation that discontinuation of the skilled service would result in the decline of the patient’s safety and functional status.

These services may be provided by a licensed assistant in that skilled service under the supervision of a licensed therapist in Physical Therapy, Occupational Therapy, or Speech Therapy.

Does Medicare cover maintenance care at home?

Medicare Part A, Part B, and Medicare Advantage Plans cover maintenance care for patients who are homebound and qualify under CMS guidelines of requiring skilled care without the need to show continual improvement.
These services include Physical Therapy, Occupational Therapy, and Speech Therapy.

Medicare and Home Health Care official government booklet

CMS was sued in 2011 for discrimination in the case (Jimmo vs Sebelius) stating that CMS was denying claims based on a rule-of-thumb “Improvement Standard” due to lack of restoration potential even though the patient required skilled care to maintain functional status and prevent deterioration.
This case was settled in 2012 in favor of the patient.

Maintenance benefits are available after the patient has met the criteria of being homebound and having clear documentation from the Physical Therapist, Occupational Therapist, or Speech Therapist, including doctor’s orders, advocating for the need for ongoing skilled care to prevent a patient’s functional deterioration.

With this documentation, the patient is eligible for Physical Therapy, Occupational Therapy, and Speech Therapy services to address maintaining their current functional ability, safety, and to slow down the deterioration or decline of their functional status.

These skilled care services can be provided in a patient’s home, in a hospital, in an outpatient rehab setting, or in a skilled nursing facility.

Maintenance programs may address general deconditioning, contractures, weakness, lack of mobility, fatigue, activities of daily living tasks, range of motion, skin breakdown, fall risk, eating and swallowing issues, and communication issues.

All of these issues qualify for maintenance care to prevent further deterioration without the need to any improvement in the patient’s current functional level.

These services may be provided by an assistant, licensed in the specific skilled service, under the supervision of a licensed Physical Therapist, Occupational Therapist, or Speech Therapist.

Does Medicare cover maintenance care for Physical Therapy?

Physical Therapy, as a maintenance program, is a covered service under Medicare Part A, Part B, and Medicare Advantage programs in an inpatient setting, outpatient setting, skilled nursing facility, or in the patient’s home through a Home Health Care Services Agency.

Physical Therapy maintenance coverage is explained by Medicare’s FAQs in question 5:

In the Jimmo vs Sebelius case of 2011, CMS was sued for discrimination when Medicare used the “Improvement Standard” and denied claims to patients who were not improving, even though the patient required continuing maintenance care to prevent further deterioration.

In 2012, the courts ruled in favor of the patient, and now skilled maintenance is a covered benefit under Medicare Part A, Part B, and Advantage programs.

Maintenance care for Physical Therapy, Occupational Therapy, and Speech Therapy are covered benefits.

Physical Therapy maintenance services may be provided in an inpatient setting, outpatient setting, home health, and an inpatient nursing facility.

The patient must meet the criteria of requiring skilled care to maintain or slow down the deterioration process.

A progressive diagnosis or chronic diagnosis is not necessary; however, justification and documentation by the licensed physical therapist are required for the ongoing physical therapy care, stating that the termination of physical therapy will result in the patient’s deterioration in the patient’s safety and functional status.

Follow-up sessions may include, but are not limited to, instructing the patient’s family or non-licensed personnel on established intervention programs developed by the Physical Therapist after the patient’s evaluation, consulting on issues that may arise with new caregiver personnel, body mechanics for the safety of the patient and caregiver, positioning of patients to maintain skin integrity, reducing fatigue, balance and strengthening programs, instructing caregivers on range-of-motion protocols to decrease contractures and maintain the safety and general function of the patient to slow down the general deterioration process.

The treatment sessions may also be provided by a licensed Physical Therapy Assistant under the supervision of a licensed Physical Therapist.

Does Medicare cover maintenance care for Occupational Therapy?

Occupational Therapy, as a maintenance program, is a covered service under Medicare Part A, Part B, and Medicare Advantage programs in an inpatient setting, outpatient setting, skilled nursing facility, or in the patient’s home through a Home Health Care Services Agency.

Occupational Therapy maintenance coverage is explained by Medicare’s FAQs in question 5:

Occupational Therapy maintenance care was included as a benefit under the Medicare program when CMS was sued in 2011 for discrimination. (Jimmo vs Sebelius) CMS had been denying or limiting coverage using the “Improvement Standard” where a patient was required to show continued progress.

In 2012, the plaintiffs were awarded the case which allowed patients access to maintenance care for Occupational Therapy, Physical Therapy, and Speech Therapy services.

Occupational Therapy maintenance care encompasses a program established by a licensed Occupational Therapist that would continue to provide skilled care to the patient to maintain function, safety, and decrease deterioration.

This benefit is available to a patient in an inpatient setting, an outpatient setting, in a nursing facility, or in their own home through a Home Health Care Agency.

Maintenance care is not diagnosis driven but is established after an initial evaluation by the Occupational Therapist that documents the need for maintenance care to prevent further deterioration of the patient’s condition.

The Occupational Therapist performs an initial evaluation, identifies the patient’s functional deficits, states the need for ongoing Occupational care to prevent further deterioration, develops an intervention program and necessary modifications, and re-evaluates the patient every 30 days.

Occupational Therapists help the patient attain and maintain their highest level of ability within a safe environment.

Occupational Therapists are trained in assessing the ongoing and changing needs of the patient, and the use of adaptive equipment for Medicare patients as they age.

The Occupational Therapist instructs the patient’s family and caregivers on the correct techniques to carry out the intervention program correctly.

By providing ongoing strategic consultation, the Occupational Therapist is adept at introducing the needed adaptive equipment to maintain patient safety, function, and independence.

In addition to the patient’s regular caregivers, the intervention programs designed by the Occupational Therapist can be provided by Certified Occupational Therapy Assistants.

Does Medicare cover maintenance chiropractic care?

Medicare does not cover maintenance Chiropractic care.
Chiropractic benefits under Medicare are specific, limited, and spelled out that maintenance therapy is an exclusion.

Chiropractic services are explained at Medicare.com.

CMS has had a history of denying claims under the “Standard Improvement” clause which states that therapy benefits are available only if the patient is making progress.

In 2011 CMS was sued for discrimination (Jimmo vs Selebrius) and in 2012 the courts ruled in favor of the patient.

Even though maintenance therapies are included in this ruling for Physical Therapy, Occupational Therapy, and Speech Therapy, Chiropractic services are not included as a benefit.

Medicare considers care for chronic subluxations as supportive and not corrective and deems it to not be medically necessary.

Other non-covered Chiropractic services include new patient exams, re-exams, X-rays, Electrical Stimulation, Massage, Laser Therapy, Kinesio taping, and mechanical traction.

All non-spinal adjustments, including all extremity joints, are not covered under Medicare.
Supplemental products and nutritional counseling are also a non-covered Chiropractic Medicare benefit

Does Medicare cover maintenance care by family members?

Maintenance care by caregivers is not a covered benefit under Medicare, however, many states have programs that will pay family members as caregivers.
The best way to find these programs and rules is to Google “Can I get paid for taking care of my elderly parents in (Name of State)?“

Other Google search terms that might provide an answer

How to get paid to take care of a family member with a disability.
How can I get paid by the state for taking care of someone?

Family caregiver pay rate.
Government assistance for family caregivers.
Paid family caregiver (Name of State)

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Medicare Maintenance Care: Who Qualifies for What Services