APTA has spoken often about the longstanding myth that Medicare does not cover services to maintain or manage a beneficiary’s current condition when no functional improvement is possible.
The Jimmo Settlement Agreement of 2013 clarified that when a beneficiary needs skilled nursing or therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits to maintain the patient’s current condition or to prevent or slow decline or deterioration (provided all other criteria are met), Medicare covers those services. Coverage cannot be denied on the basis of potential for improvement or restoration.
Unfortunately, the "improvement standard" has been retained by many third-party payers — restricting beneficiaries’ access to maintenance care and the continued services of PTs and PTAs. In 2018 APTA’s House of Delegates charged the association to "develop and implement a long-term plan to eliminate the improvement standard in all settings and payment situations." APTA staff has been working diligently with commercial insurance and employer partners on this issue.