Question
How do the legal foundations and goals of a Functional Maintenance Program differ from a traditional Part B plan of care?
Answer
Grounded in the landmark Jimmo v. Sebelius settlement, functional maintenance programs establish that a Medicare beneficiary's lack of restoration potential cannot serve as the sole basis for denying therapy coverage. Traditional Part B plans focus on restorative progress, whereas maintenance programs are designed by a therapist to optimize safety, maintain current functional status, or slow clinical deterioration. The justification for these programs hinges on whether the required care demands the unique clinical judgment and skills of an OT professional rather than those of a non-skilled caregiver. Consequently, documentation must clearly state the resident's progressive prognosis and precisely outline why skilled intervention is necessary to prevent functional decline.
This Ask the Expert is an edited excerpt from the course, Building a Part B Caseload in the LTC Setting, presented by Elizabeth Alicea-Torres, OT, OTD, OTR, CAPS.
Continued and its subsidiaries provide professional education authored by qualified Subject Matter Experts for continuing education purposes. These materials are intended for educational purposes and do not constitute medical advice or a substitute for individual clinical judgment. Continued is not a clinical healthcare provider; the licensed professional is solely responsible for ensuring that the application of any techniques or information presented is within their legal scope of practice and jurisdictional requirements.
