Medicare Part B is Not a Plan B

Skilled Therapy Under Medicare Part B: Ensuring Long-Term Residents Are Not Forgotten

KENNESAW, GA / ACCESS Newswire / February 10, 2026 / Studies consistently show that most long-term residents in skilled nursing facilities rely on Medicaid to assist with the cost of long-term care. With the transition to a Patient-Driven Payment Model (PDPM) for Medicaid reimbursement, states now have discretion in determining which PDPM components are included in their reimbursement model.

Of the five PDPM components, Nursing, Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology (ST), and Non-Therapy Ancillaries (NTA), some states have chosen not to include therapy services within the bundled Medicaid payment.

However, two critical considerations remain:

1. Therapy services continue to be reimbursable as ancillary services under Medicare Part B or Medicare Advantage (Managed Part B) for approximately 63-77% of nursing home residents, many of whom are dual-eligible.

2. Read moreFossil launches its first smartwatch on the Qualcomm Snapdragon Wear 3100 platform

   Quality Measures, survey outcomes, patient satisfaction, and public reviews will decline when appropriate therapy services are underutilized-particularly those aimed at improving function, maintaining function, or slowing functional decline.

This article explores how this reimbursement shift can affect long-term care residents and outlines actionable strategies facilities can use to ensure that no resident is left behind.

Medicare Part B: Your Answer to Reimbursement Challenges

Many long-term care residents who receive Medicaid benefits are also enrolled in Medicare Part B, which is a key reason some states have opted not to include therapy case-mix indexes (CMIs) in their Medicaid PDPM models.

For facilities operating in states where therapy is excluded from Medicaid PDPM reimbursement, Medicare Part B serves as a vital pathway to ensure continued reimbursement for medically necessary therapy services provided to long-term care residents.

“Medicare Part B covers ancillary services such as therapy when a resident experiences a medical, physical, or cognitive decline that requires skilled intervention”, stated Melinda Henderson, BenCura’s Chief Development Officer. “Think of someone living in their own home who becomes weaker – perhaps due to a urinary tract infection, a sedentary lifestyle, or reduced mobility,” she continues. “Therapy would be recommended to help them regain or maintain function. The same clinical logic applies in the nursing home setting. That is where Medicare Part B becomes essential.”

Common Pitfalls With Medicare Part B in Long-Term Care

While Medicare Part B is a powerful reimbursement solution for therapy services in long-term care, one major barrier often stands in the way: familiarity.

Some therapy needs are immediately apparent, such as falls resulting in injury, pain, or fear of mobilization. Other obvious triggers may include choking episodes, splinting needs, or pain.

However, many functional declines occur gradually, making them difficult to detect through routine observation alone.

“When we work in skilled nursing settings, we see residents every day, which makes it harder to recognize subtle changes over time,” Henderson explained. “I compare this to aging. You don’t look in the mirror and notice aging from one day to the next. However, when you look at a photo from a few years ago, the change is clear.” This same phenomenon occurs in long-term care residents: slow, incremental functional decline that is easy to overlook without objective measurement.

How Standardized Assessment Tools Prevent Residents From Being Overlooked

Standardized assessments address the challenge of gradual decline by providing objective, repeatable data points that compare a resident’s current function to prior performance.

These tools allow facilities to proactively identify physical or cognitive changes before they result in adverse outcomes such as falls, hospitalizations, or loss of independence.

“At BenCura, standardized assessments are a foundational component of clinical practice,” Henderson shared. “They help us identify statistically significant changes that may not be visible to the naked eye.”

For example, a therapist may observe a resident ambulating independently with a walker both before and after a fall and conclude there is no functional change. However, administering a Tinetti Balance Assessment may reveal a decline from 24/28 (low fall risk) to 21/28 (moderate fall risk)-a statistically significant change that establishes medical necessity for Medicare Part B services. Without standardized tools, this decline may go unnoticed.

Ensuring Objectivity and Reducing Bias

Standardized assessments also play a critical role in minimizing unconscious bias.

“When we see residents every day, we can become desensitized,” Henderson noted. “These tools help us evaluate residents objectively; regardless of familiarity, assumptions, or personal perceptions.”

She highlights two common scenarios:

• “Repeat Offenders” – Residents or family members who frequently request therapy services. While not every request results in skilled need, repeated requests should not automatically be dismissed. Functional decline can still occur.

• “Terminal Cuteness” – Residents who are especially pleasant or endearing may unintentionally receive less scrutiny due to unconscious bias. Standardized tools help ensure all residents are evaluated consistently and equitably.

Additional Considerations for Long-Term Care Facilities

Beyond Medicaid reimbursement changes, facilities must also account for several evolving regulatory and clinical considerations:

• CMS Final Rule changes related to fall coding – Facilities may experience an increase in reportable falls, making timely therapy referral and intervention critical.

• Documentation differences between Nursing and Therapy – Nursing documentation does not align with therapy documentation. For example, when nursing documents late-

Loss ADL – bed mobility, transfers, toileting, and eating, the coding for extensive assistance in nursing documentation, can be either min, mod, or max assistance in therapy documentation. Standardized assessments help bridge this gap.

• Debunking the “Improvement Only” Myth – Therapy does not always need to result in functional gains to be reimbursable. Maintenance therapy, when medically necessary and properly documented, remains a valid and reimbursable service under Medicare Part B. Other examples of therapy that may not involve functional gains include establishing functional maintenance programs, and caregiver training.

How BenCura Can Help

BenCura partners closely with skilled nursing facilities to ensure therapy services are clinically appropriate, compliant, and financially sustainable. Our team supports facilities by:

• Implementing and training staff on standardized assessment tools

• Identifying appropriate Medicare Part B opportunities

• Supporting restorative and maintenance programming

• Educating staff on documentation and coding best practices

• Aligning therapy services with quality measures and survey readiness

If your facility needs support in ensuring long-term care residents are not overlooked; while maximizing reimbursement across Medicaid, Medicare, and private payers, schedule a complimentary discovery call today.

About BenCura Rehabilitation Services

BenCura is a premier contract rehabilitation partner delivering high-quality physical, occupational, and speech therapy at a lower total cost of care than traditional in-house models. Serving acute care hospitals, critical access hospitals, and skilled nursing facilities, BenCura integrates clinical excellence with operational rigor and data-driven transparency.

Learn more at bencura.com.

CONTACT:

855.423.6287
info@bencura.com

SOURCE: BenCura

View the original press release on ACCESS Newswire