An important improvement in Medicare coverage -- please spread the news

[pnwmom]

to people on Medicare and their family members.

http://newoldage.blogs.nytimes.com/2014/03/25/a-quiet-sea-change-in-medicare/?action=click&contentCollection=U.S.&module=MostEmailed&version=Full®ion=Marginalia&src=me&pgtype=article

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.

No more. In January, Medicare officials updated 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.

SNIP

[Cleita]

1. Good to know. We all need exercise, but for old people it's better

to have a trained therapist guide you so you don't injure yourself with the wrong moves.

[Suich]

2. This is exellent news!

I have a friend who has home hospice care. Medicare used to quit paying for it after 90 days, which never made any sense to me.

Thanks for posting!

[jwirr]

3. This will be especially important to people like my brother who is bi-polar. What has happened in

the past is when he did not improve but was just maintaining they would cut him off from his therapist. The only time he could go back was when he was so bad we feared for his life. Then they would take him back. This is a ridiculous way to treat mental illness.

[William769]

4. Kick & recommended.

[DeSwiss]

5. K&R!

- TY

[center][/center]

[geretogo]

6. How did something good like this slip by Republicon evil eyes ?

[SoapBox]

7. K & R

[madfloridian]

8. Too late for us.

Of all the things my late husband needed in rehab it was physical therapy. They dropped him from it because of their criteria....he needed it for leg circulation. Bitter much? maybe.

[FloriTexan]

9. Yes, very bitter....

It would have helped my MIL too, but they dropped her as well because she wasn't "improving" or "cooperating". Bitter yes. Very. Every little bit of therapy like this helps. Dad would have done it and cooperated as much as he could. At least now, someone else can benefit. Sigh.

[MannyGoldstein]

10. It's a great thing... but...

My wife got some experience with this recently, dealing with a relative's issues.

This has actually been law for more than a year, even though the manual was just updated. HHS changed it to settle a lawsuit.

While it's now law, nobody quite knows what it means yet because there's no case law, i.e., no cases have gone through the courts that functionally define the changed law. As a result, we're finding that providers near us (Massachusetts) are still very reluctant to bill Medicare for treating folks who've "plateaued", because they're afraid of getting their claims denied or getting nailed for Medicare fraud.

That doesn't mean that people shouldn't push for services under the new law - just be prepared for pushback.

[pnwmom]

11. Well, there has been the case that resulted in the manual update.

But it does sound like people may still have to fight for this.

From the article in the OP:

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.

SNIP


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.