APTA continues to make progress, through recommendations to commercial and other nonfederal payers, to eliminate what's often referred to as the “improvement standard”—the potential for improvement as a condition of coverage for skilled therapy services. This so-called standard was called out in the 2013 Jimmo v Sebelius ruling that clarified Medicare's longstanding policy of covering skilled therapy services based on the need for skilled care, regardless of the presence or absence of a beneficiary's potential for improvement.
APTA's recommendations support payment for services requiring the skills of a physical therapist or physical therapist assistant to ensure that a patient doesn't experience an avoidable decline in function even if improvement is not anticipated. APTA will continue to work with commercial payers to promote adoption of policy changes that improve access to medically necessary services and promote the role of physical therapy in the prevention of functional decline. The following payers have adopted language and or revised policies to remove the improvement standard or to cover maintenance therapy. Implementation and the extent of the benefit vary by payer.
Read more about skilled maintenance coverage under Medicare.
If you are aware of other payers adopting policy language related to the improvement standard or maintenance therapy, please contact APTA at firstname.lastname@example.org.
Last Review Date
|AmeriHealth and Independence BC
||(Policy was updated to remove maintenance therapy as a benefit contract exclusion.)
Maintenance therapy provides a continuation of care and management of an individual when the therapeutic goals of a plan of care have been achieved, no additional functional improvement is apparent or expected to occur, and the provision of services for a condition ceases to be of therapeutic value.
|Blue Care Network of Michigan
||Physical and Occupational Therapy (Outpatient)
Skilled care may be necessary to improve a patient's current condition, to maintain the patient's current condition, or to prevent or slow further deterioration of the patient's condition.
Jimmo settlement states: Coverage of skilled nursing and skilled therapy services in the skilled nursing facility, home health, and outpatient therapy settings does not turn on the presence or absence of a beneficiary's potential for improvement, but rather on the beneficiary's need for skilled care. Skilled care may be necessary to improve a patient's current condition, to maintain the patient's current condition, or to prevent or slow further deterioration of the patient's condition.
CMS Publication 100-02 Medicare Benefit Policy Manual, Chapter 15: Section 220: Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance (Rev. 255, Issued: 1/25/19, Effective: 1/1/19; Implementation 2/26/19)
|BCBS of North Carolina Medicare Part C
||Improvement standard: The restoration potential of the individual is not the deciding factor in determining whether skilled services are needed. Coverage depends on whether
skilled care is required. Conversely, coverage would not be available in a situation where the beneficiary's care needs can be addressed safely and effectively through the use of nonskilled
||Physical and Occupational Therapy Services Version 1.0.2019 Skilled Maintenance Care
Maintenance care is defined as services required to maintain the member's current condition or to prevent or slow deterioration of the member's condition.
Skilled maintenance care for Medicare and Medicaid enrollees is covered if the specialized skill, knowledge and judgment of a qualified therapist are required:
Skilled care is necessary for the performance of a safe and effective maintenance program only when:
- To establish or design a maintenance program appropriate to the capacity and tolerance of the member
- To educate/instruct the member or appropriate caregiver regarding the maintenance program
- For periodic re-evaluations of the maintenance program
- For delivery of maintenance programs
- the therapy procedures required to maintain the patient's current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a
qualified therapist are required to furnish the therapy procedure.
- (b) the particular patient's special medical complications require the skills of a qualified therapist to furnish a therapy service required to maintain the patient's current function or to prevent or slow further deterioration, even if the skills of a therapist are not ordinarily needed to perform such therapy procedures.
- The need for maintenance care is not determined by the presence or absence of a member's potential for improvement but by the need for skilled care.
- Skilled Maintenance Programs in an Outpatient and Home Health setting will not be covered if furnished by a Physical Therapist Assistant. (Chapter 15, Section 220.2 Subsection D of the Medicare Benefit Policy Manual).
- eviCore will authorize maintenance care when the member's plan of care establishes that the member requires the specialized skill, knowledge and judgment of a qualified therapist to
maintain the member's current condition or to prevent or slow deterioration of the member's condition.
|Health New England
||Skilled care services. Skilled care services include home health care and skilled nursing facility or skilled unit or sub-acute facility or unit care that is covered when medical
necessary and prior approved by the plan. Skilled nursing and/or skilled rehabilitation services are those services furnished pursuant to physician order that require the skills of
qualified professional health personnel such as physical therapist.
Guidelines for Physical and Occupational Therapy
If after the initial evaluation of the extent of the disorder, illness, or injury, the treating qualified professional determines the potential for rehabilitation is insignificant, an
appropriate maintenance program may be established prior to discharge. Since the skills of a therapist are required for the development of the maintenance program and training of the member
or caregivers, this service is covered,
If the services required to maintain function involve the use of complex and sophisticated therapy procedures, the judgment and skill of a therapist may be necessary for the safe and
effective delivery of such services. When the patient's safety is at risk, those reasonable and necessary services shall be covered, even if the skills of a therapist are not ordinarily
needed to carry out the activities performed as part of the maintenance program.
|Independence BC Medicare Advantage
||Maintenance Therapy: Outpatient PT and/or OT services may be authorized when skilled services are medically necessary to establish a maintenance program. Medical record documentation
must confirm the specialized skills, knowledge and judgment of a qualified therapist are required to:
Once a maintenance program is established, the determination of medical necessity for skilled therapy services to carry out the maintenance program is based on the member's need for skilled
care. Coverage for therapy services to carry out a maintenance program does not depend on the presence or absence of the patient's potential for improvement from the therapy.
- Establish and/or design a maintenance program intended to maintain the patient's current condition, or prevent or slow further deterioration; OR
- Instruct the patient and/or appropriate caregiver regarding the maintenance program; OR
- Periodically reevaluate and/or reassess the effectiveness of the established maintenance program; OR
- Deliver skilled therapy components of the maintenance program.
|UnitedHealthcare Medicare Advantage Plans
Maintenance program is a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she
has made during therapy or to prevent or slow further deterioration due to a disease or illness. Skilled therapy services that do not meet the criteria for rehabilitative therapy may be
covered in certain circumstances as maintenance therapy under a maintenance program. The goals of a maintenance program would be, for example, to maintain functional status or to prevent or
slow further deterioration in function. For more detailed guideline, see the Medicare Benefit Policy Manual, Chapter 15, §220.2D-Maintenance Programs. (Accessed March 27, 2019)Also see the
Medicare Benefit Policy Manual, Chapter 15, §220 -Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services)
Under Medical Insurance, A-Definitions.(Accessed March 27, 2019)