Ever since Cindy Hasz opened her geriatric care management business in San Diego 13 years ago, she has been fighting a losing battle for clients unable to get Medicare coverage for physical therapy because they “plateaued” and were not getting better.
“It has been standard operating procedure that patients will be discontinued from therapy services because they are not improving,” she said.
Paul O. Boisvert for The New York TimesGlenda Jimmo at home in Lincoln, Vt., in 2012. She was the lead plaintiff in a lawsuit over whether Medicare should pay for treatment for people whose underlying conditions were not likely to improve.
No more. In January, Medicare officialsupdated the agency’s policy manual — the rule book for everything Medicare does — to erase any notion that improvement is necessary to receive coverage for skilled care. That means Medicare now will pay for physical therapy, nursing care and other services for beneficiaries with chronic diseases like multiple sclerosis, Parkinson’s or Alzheimer’s disease in order to maintain their condition and prevent deterioration.
But don’t look for an announcement about the changes in the mail, or even a prominent notice on the Medicare website. Medicare officials were required to inform health care providers, bill processors, auditors, Medicare Advantage plans, the 800-MEDICARE information line and appeals judges — but not beneficiaries.
Ms. Hasz said she was shocked when she heard the news. “This is a sea change,” she said.
The manual revisions were required in the settlement to a class-action lawsuit filed in 2011 against Kathleen Sebelius, the secretary of health and human services, by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of four Medicare patients and five national organizations, including the National Multiple Sclerosis Society, Parkinson’s Action Network and the Alzheimer’s Association. The settlement affects care from skilled professionals for physical, occupational or speech therapy, and home health and nursing home care, for patients in both traditional Medicare and private Medicare Advantage plans.
“It allows people to remain a little healthier for a longer time and stay a little bit more independent,” said Margaret Murphy, associate director at the Center for Medicare Advocacy. And it eases the burden on families who “are scrambling to take care of their loved ones,” she said.
The change may have the most far-reaching impact on seniors who want to avoid institutional care. People with chronic conditions may be able to get the care they need to live in their own homes for as long as they need it, Ms. Murphy said, if they otherwise qualify for coverage.
Existing eligibility criteria haven’t changed. Although seniors probably won’t hear the words “plateau” or “improvement” when coverage is denied, they can still lose coverage for reasons other than a lack of improvement.
For nursing home coverage, you must have a doctor’s order prescribing skilled nursing home care (not custodial care), and you must have spent three consecutive midnights in the hospital as an admitted patient (observation days don’t count). Limits on the duration of Medicare nursing home coverage remain the same.
Physical and speech therapy ordered by a doctor and provided in a nursing home or an outpatient facility by a skilled professional are subject this year to a $1,920 therapy cap. Providers can get an automatic exception to the cap for medically necessary treatment until costs reach $3,700. At that point, another exception is possible after Medicare reviews medical documentation. (Occupational therapy is provided to patients with separate $1,920 and $3,700 caps, with the same exceptions.)
For home health coverage, you must have a doctor’s order for intermittent care — every few days or weeks — provided by a skilled professional for outpatient therapy, social work services or a visiting nurse.
The therapy caps do not apply in the home setting so long as the patient is “homebound,” and that doesn’t necessarily mean confined to bed. Someone who is homebound requires “considerable and taxing effort to leave home,” Ms. Murphy said, and cannot do so without another person or a wheelchair, walker, cane or other device.
Beneficiaries receiving skilled services at home are also eligible for home health care aides for assistance with bathing, dressing and other daily activities.
The settlement also establishes a special “re-review” procedure for claims that were denied in the past three years solely because patients were not improving or because their care was intended to maintain their condition.
Officials have posted a form beneficiaries can use to request reimbursement if they paid for care themselves. The form must be submitted by July 23, 2014, for claims with a final denial dating from Jan. 18, 2011, through Jan. 24, 2013.
Requests for review of denials received Jan. 25, 2013, through Jan. 23, 2014, are due Jan. 23, 2015. If the claim is denied again, a Medicare spokesman said, beneficiaries may appeal through the regular appeals process.
But what if, despite the settlement, your provider or a Medicare representative still says you can’t continue treatment only because you are not improving?
First, point them to Medicare’s online fact sheet about the settlement, which clearly says, “Coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required.” (And let us know what happens.)
If that doesn’t work, contact your state Quality Improvement Organization for help filing an expedited appeal. Ask the doctor who ordered treatment for a letter of support.
If you receive the treatment and pay for it yourself (or are on the hook for the bill), Ms. Murphy suggests asking the provider to bill Medicare. Then you should appeal the denial by following the instructions provided on your Medicare summary notice or in the appeal decision letter. The Center for Medicare Advocacy’s websiteprovides more details.
If all else fails, email the center’s lawyers atimprovement@medicareadvocacy.org. They are meeting regularly with Medicare officials to monitor compliance with the settlement and will tell the agency about coverage denials prohibited in the settlement. Despite Medicare’s efforts to get the word out, the center still receives complaints every week from people denied treatment only because they are not getting better.