Question re: Therapy when insurance has paid out the max and no other funds?

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.

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),
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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 Sidebar: "Not Making Progress," is an old outdated excuse overturned, ejected out of the vernacular of CMS (2013 Jimmo vs. Sebelius).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.
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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.

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?

Hirshy: Perhaps you meant to state that your MIL is on Medicare since she is 76 years of age. Did her physician sign off on the PT? The physician will have to provide extra information on her medical record when deemed necessary.

Hirshy, another thought...do you know if she used, or can use, one of the "bike medal" machines?    They're like a cut-away of the pedals, and can be used either for increasing arm or leg strength.  

There are reasonably priced versions, such as this:

http://quibids.com/en/item-1683650-wakeman-fitness-folding-pedal-exerciser-with-electronic-display

This is a higher end version though, with an electronic readout for gauging miles pedaled.

Catalogues like Miles Kimball, Carol Wright and others in that price range also sell them.    WalMart apparently offers them as well.

Rehab facilities typically have the more expensive versions, like these:

https://www.walmart.com/ip/Office-Sitdown-Pedal-Machine-Design-Exercise-Mini-Peddler-Under-Desk-Bike-Stationary-Small-Cycle-Leg-Foot-Portable-Recumbent-Equipment-Low-Impact-You/960290239

Either version can be set on the floor for leg exercise (while the individual is safely seated in a chair), or on a table for arm exercise.   If you do use the first (cheaper) version on a tabletop, consider putting something heavy on the base (or use some type of clamp) so the device doesn't move around.   Or set something underneath the bases to keep them from sliding.    Nonslip place mats could work.

You might be able to get either version at a local DME supply store.

They're great for strengthening arms and legs while seated, and in safety.

What I did for my parents was to meet initially with the therapists to introduce myself and share with hem that I would be sometimes be participating in therapy to observe the exercises and ensure I knew how to do them once PT was discontinued.   

We discussed and they provided handouts, generally on all the exercises, so Mom or Dad could do them at home.  I did them too, so they wouldn't feel as if they were performing.

They were followed with treats:  either Mom or Dad's favorite music, or a walk, or something that finished off the session in a positive frame of mind.

First of all, appeals can be made and sometimes you succeed in more funding coming. In the event it stops, I assume that the PT people have taught he how to do certain exercises, walking, etc. If they are out of the picture, there is NO reason she can't continue on her own. She MUST MAKE THE EFFORT WITH NO CHANCE FOR REFUSAL.

From personal experience, when I had shoulder repair, I needed physical therapy. When the first period expired and I still couldn't do the actions required in life (like fasten my bra behind my back, lift heavier items, etc. ), I was granted an extra 6 weeks after a period of time I think a month or more off therapy. Same with my husband's knee replacement therapy. The first 6 weeks didn't do much help, but was also granted another 6 weeks after a while, and discussion with his physician.

learn how to do the exercises yourself and do them with her. Physical Therapy should have provided this information. Otherwise she will be going to a nursing home. Can't be on physical therapy forever.

From what I understand about the PT, it is intended to get them to a certain level and hand it over to the patient to keep doing what the PT shows them. I also found that the patient comes off the PT, but can go back on after a month or two break in services. (For medicare patients) Start with the PT people by asking if there is a way to get it continued - it's all about the evaluation they do. You may have to call her doctor to see if he can submit more paperwork.

That's how it worked for me w/my mom. However, I know another lady that even refuses to do the PT when they show up, but it never gets denied. She continues to get a weekly nurse visit, PT, and weekly bath. All I can figure out is the doctor knows how to document it for her.

I highly recommend Sit And Be Fit, which is available on YouTube with Mary Ann Wilson, RN. She has posted over 70 videos and her show has won many awards because it is designed by her in collaboration with doctors and exercise physiologists. Your MIL can start watching those videos and doing the exercises.

If she has been getting therapy for months is she in a position to do strength training on her own?

I know that I had to call my dad multiple times daily to encourage him to get up and move and then I took him shopping with me 4 days a week and walked up and down every isle in the big box stores. It helped him and I don't think he ever realized that I was doing my shopping 1 or 2 items at a time.

Can you help her in person or by calling her and reminding her to do the exercises that she has been given by her therapist?

I felt like my dad would prove what he really wanted by what he did without an audience. He got a lot more mobile and even started driving again. If she really wants to get better she will put the effort in even without the therapist.

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."

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.

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.

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

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.

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.

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).