What Medicare Will Cover Even if You’re Not Likely to Get Better

It didn’t, for many years. But after the settlement of a landmark class-action lawsuit this week, Medicare will soon begin paying more often for physical, occupational and other therapies for large numbers of people with certain disabilities and chronic conditions like Alzheimer’s disease, multiple sclerosis and Parkinson’s disease.

The two questions patient advocates were left with this week were just how many people may benefit from the clarification of the regulations and how quickly.

The settlement, if approved by a federal judge, would end a lawsuit that accused Medicare of allowing the contractors that process its claims to use a so-called improvement standard over the last few decades. To the Center for Medicare Advocacy and the many other organizations that joined the suit, that standard seemed to call for cutting off physical, occupational and speech therapy and some inpatient skilled nursing for many people who had reached a plateau in their treatment.

Medicare is supposed to pay for reasonable treatment of an illness or injury as long as a doctor has prescribed it. For the sort of in-home care that this week’s settlement may affect the most, a doctor must have certified that you are, in fact, homebound and have prescribed treatment that only a skilled practitioner can provide. (The “skilled practitioner” rule keeps Medicare from paying for assistance with everyday activities like bathing and dressing.)

But for people who advocate for patients with particular diseases, having treatment cut off for lack of improvement was intensely frustrating.

“The idea that you would have to show improvement when you have a degenerative disease is blatantly absurd,” said Amy Comstock Rick, chief executive of the Parkinson’s Action Network. In her world, holding steady or degenerating more slowly than you might otherwise is often the definition of success.

Over the years, however, the Medicare contractors that process claims started to see things differently than patients and many health care professionals. And for family members of the sick, the denial could be quite abrupt.

“It was like falling off a cliff in that there was no longer any access to Medicare to help with even small, maintenance types of things, like range of motion,” said Maureen Conte, a Falmouth, Mass., scientist, recalling the six years her father lived after having a stroke. “Multiple times he was back in the hospital for things that I thought were preventable.”

Many other patients, however, may not have even received certain kinds of treatment because their doctors figured that prescribing it would be pointless. “Once it becomes clear what Medicare will and will not pay for, you end up changing your practice pattern based on what it covers,” said Peter Thomas, a lawyer in private practice who is the outside counsel for the American Academy of Physical Medicine and Rehabilitation.

The settlement agreement takes pains not to describe itself as an expansion of Medicare coverage. But it does promise that the Centers for Medicare and Medicaid Services will revise the manuals their contractors use to make clear that coverage “does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy but rather on the beneficiary’s need for skilled care.”

Moreover, the settlement specifies that skilled care can qualify for Medicare coverage even if it merely maintains someone’s current condition or prevents or slows further deterioration. Certain patients who have had claims rejected will be able to resubmit them.

Representatives of several patient advocacy groups expressed hope this week that Medicare would soon pay for many forms of therapy that it did not always cover before.

For people with cerebral palsy, physical therapy to maintain muscle mass is one possibility. For multiple sclerosis patients, there may be more approval for treatments for spasticity and gait training to prevent falls.