Major Breakthrough in Medicare Coverage for Chronic Illnesses

hands of old and youngFor years we have accepted the fact that Medicare will only cover physical therapy for patients who are continuing to improve. When my mother broke her hip the therapists informed her doctor that Medicare coverage for rehabilitation would cease after only three weeks of therapy. They told us that she would have to return to her assisted living residence even though she was still not able to walk. Their conclusion: She was no longer improving and it was likely she would never walk again.

Of course this was complicated by the fact that she had dementia and couldn’t remember the exercises they had prescribed for her a few minutes after she left the therapy room. But we accepted their conclusion without making a fuss and she has been in a wheelchair for the last five years.

But a major change has recently occurred in Medicare. One that has been kept very quiet but will have a huge impact on patients who have chronic illnesses. Medicare officials updated the agency’s policy manual in January. This is the rule book for everything Medicare does.  They stated that Medicare will now pay for physical therapy, nursing care and other services for beneficiaries with chronic illnesses like Multiple Sclerosis, Parkinson’s and Alzheimer’s disease in order to maintain their condition and prevent deterioration.

This dramatic change is due to the settlement of 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 care, for patients in both traditional Medicare and private Medicare Advantage plans.

The change will have the greatest impact on seniors who want to avoid having to go into an institution to get care. People with chronic illnesses like Parkinson’s or MS may be able to get the care they need and stay in their own homes.

Existing eligibility criteria for Medicare rehabilitation benefits have not changed however. To be admitted to a rehab. facility or nursing home for covered care the patient must have spent three consecutive midnights in the hospital as an admitted patient and the patient must be referred by a Doctor’s order prescribing skilled nursing home care not custodial care.

For home health coverage, the beneficiary must have a Doctor’s order for intermittent care ( every few days or weeks) provided by a skilled professional or outpatient therapy, social work services or a visiting nurse. 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 provides for a review of claims that were denied in the past three years solely because patients were not improving. Officials have posted a form on the Medicare site to repay beneficiaries for the care they paid for themselves. This form must be submitted by July 23, 2014 for claims that were denied from Jan. 18, 2011 to Jan. 24, 2014. Claims denied between Jan. 25, 2013 and Jan. 23, 2014 must be submitted by Jan. 25, 2015