A legal deal proposed by the Obama administration may soon make it easier for Americans with chronic health conditions to receive assistance from Medicare federal health insurance to help cover the costs of skilled nursing home stays, home health care and therapy.
Under a decades-old Medicare "improvement standard," beneficiaries have been required to convince the feds that there was a likelihood of medical or functional improvement before Medicare would pick up the tab for the needed services and therapies. That standard, while never written into law, has long been included in the Medicare benefit manual.
But, in a proposed settlement to a nationwide class-action lawsuit, the government has agreed to tweak that Medicare rule. Under the planned new rule, Medicare would pay for such services if they are needed to "maintain the patient's current condition or prevent or slow further deterioration," regardless of the likelihood for improvement. The move aligns well with health care reform and its focus on cost-cutting through preventive care.
The agreement that includes the proposed Medicare rule change was hammered out by lawyers from the Departments of Justice and Health and Human Services. The deal is now before a federal judge in Vermont, home to the lawsuit's lead plaintiff. The judge is expected to approve the settlement, and that would give her the authority to enforce it for up to four years.
Judith Stein, a lawyer for the nonprofit Center for Medicare Advocacy, which represented the plaintiffs, says the rule change will benefit not only tens of thousands of Americans with such chronic conditions as stroke, Alzheimer's disease, multiple sclerosis and traumatic brain and spinal cord injuries, but also their families and caregivers.
"These individuals have been denied Medicare coverage and access to medically necessary care for decades," Stein says. "As the population ages and people live longer with chronic and long-term conditions, the government's insistence on evidence of medical improvement threatened an ever-increasing number of older and disabled people. We have finally been able to eliminate this illegal, harmful, unfair application of the law."
Patient advocates admit they have no idea how many Americans might benefit from the rule change because the longstanding use of the improvement standard prevented so many from ever filing claims for Medicare benefits in the first place.
While no one is yet predicting how much the rule tweak might cost the government, Stein says additional benefit outlays may be offset, because treating the chronically ill at home and in skilled nursing facilities will help prevent far more expensive hospitalizations.
What's your diagnosis? Will the rule change help or hinder Medicare?