As ElderLawAnswers reported, the Obama Administration has agreed to end Medicare’s longstanding practice of requiring that beneficiaries with chronic conditions and disabilities show a likelihood of improvement in order to receive coverage for skilled care and therapy services.
This ruling could have a profound impact on the lives of Medicare beneficiaries who need some sort of skilled care to maintain their current level of functioning or to avoid further deterioration. In the past, Medicare was leaving these patients to pay for their own care (or go on Medicaid) if they were not improving as a result of the care they received. This often left people with conditions like multiple sclerosis, Alzheimer's disease, Parkinson’s disease, ALS (Lou Gehrig’s disease), diabetes, hypertension, arthritis, heart disease, and stroke out in the cold. (This is by no means a complete list of conditions.)
Now, with the change in policy, patients who have “plateaued” but still need the assistance of a skilled professional like a nurse or other qualified therapist will be eligible for all of Medicare’s standard benefits. Those enrolled in Part A, which covers hospitalizations, will be eligible for up to 100 days in a skilled nursing facility provided it follows a three-day hospitalization, as well as up to 100 home visits following a hospitalization. Those also enrolled in Medicare Part B, which covers doctor visits and other outpatient services, are eligible for potentially unlimited home visits.
It is unclear to what extent the policy change will increase Medicare coverage for those suffering from dementia. It will not affect the many elderly who simply need unskilled help with activities of daily living like eating, dressing, and bathing. Medicare does not pay for such “custodial” care, which is covered only by long-term care insurance or Medicaid. But if the interventions of a skilled professional would delay the progression of dementia, it arguably should be covered.
This could include, for example, the work of occupational therapists who specialize in helping dementia sufferers function, or speech therapists who teach stroke and Parkinson's patients how to regain vital communications skills.
What Can Beneficiaries Do Now?
If you are among more than 10,000 Medicare beneficiaries whose claim for skilled care received a final denial from Medicare after January 18, 2011, because you weren’t showing improvement, you are entitled to a reexamination of your claim.
Going forward, beneficiaries will have to educate providers and advocate for their benefits until this change becomes as much a part of the Medicare culture as was the previous policy of non-coverage.
"It will take a while for this to be operationalized," Joe Baker, president of the Medicare Rights Center, told Reuters columnist Mark Miller. As part of the settlement, the government must mount a nationwide educational campaign to communicate the policy standards to Medicare providers and contractors, but this could take well over a year.
Miller offers some tips for advocating for coverage on your own, including asking skilled nursing facilities or home health care providers how they plan to implement the change and contacting your State Health Insurance Assistance Program (SHIP) and the Medicare Rights Center. (To read Miller’s column, click here.) And of course your elder law attorney stands ready to help.