The Obama administration is in the process of making policy changes that may make it easier for those with disabilities and chronic conditions to qualify for Medicare disability at home care, stays at nursing homes, and outpatient therapy. A proposed settlement resulting from a nationwide class action lawsuit is behind the changes.
The old practice required beneficiaries to show a likelihood of medical or functional improvement before Medicare would step in and pay for any skilled nursing and therapy services. This outdated rule left those with many illnesses and injuries without the insurance coverage they needed.
In the settlement, the federal government agreed to make changes to the wording of the Medicare manual to ensure that a service like nursing or therapy “does not turn on the presence or absence of an individual’s potential for improvement,” but rather is based on the need for the service, regardless of the outcome.
“As the population ages and people live longer with chronic and long-term conditions,” Judith Stein, director of the nonprofit Center for Medicare Advocacy and a lawyer for beneficiaries said, “the government’s insistence on evidence of medical improvement threatened an ever-increasing number of older and disabled people.”
The old wording most negatively affected patients with Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, stroke, and spinal cord or brain injuries, as these people are not likely to improve, but need the skilled care regardless.
Dr. Lynn Gerber, director of the Center for Study of Chronic Illness and Disability at George Mason University in Virginia, stated that the settlement was “a landmark decision for Medicare recipients with chronic illness and especially those with disability.”
“Disability frequently accompanies many chronic conditions,” she said, “and we often have no cures, so people are likely to experience progressive disability. Rehabilitation, physical and occupational therapy, and skilled care are incredibly important in maintaining a person’s functional ability, performance and quality of life.”
Additional requirements of the settlement include requiring the federal court in Vermont to certify a nationwide class of more than 10,000 people who were denied claims for skilled nursing and therapy services before January 18, 2012. Medicare officials will be required to host an education campaign to publicize the changes among health care providers, government employees and contractors who make decisions regarding the coverage of these services. It is important to understand that the settlement does not guarantee coverage.