A nursing home resident’s right to therapy services does not end when Medicare coverage ends. Once a resident is eligible for Medi-Cal, certain therapy services are covered under the Medi-Cal rate. Generally, these “inclusive” services are not really therapies at all in the traditional sense, as—depending on the care plan—they include such things as range of motion exercises, encouraging residents in self-feeding or dressing, or repetitive exercises.

Other, more extensive therapies delivered by a licensed therapist can be obtained, which are separately reimbursable under the Medi-Cal program, if the provider submits a Treatment Authorization Request (TAR) when it is determined that additional services must be rendered to attain or maintain the highest practicable level of care.

Basically the therapy services requested need to be patient specific, beyond what is currently included in the nursing home rate (which leaves a large hole), and there is a need for the therapies to be delivered by a licensed therapist. For example, the resident’s plan of care calls for speech therapy for a post-stroke patient who is dysphasic. In these cases, a care planning meeting which includes the resident’s doctor is recommended. Ask the doctor to document the need for additional therapy to be provided by a licensed therapist.

Far too often, nursing home residents’ therapies end when their Medicare coverage ends, leaving residents with atrophied limbs, inability to swallow, and progressive weakness. This is contrary to both state and federal laws, and consumers need to be more assertive in demanding the therapies residents need. For more information on Medi-Cal covered therapies, contact the CANHR office.