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Medicare tweaks chronic coverage

By Jay MacDonald ·
Friday, October 26, 2012
Posted: 10 am ET

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?

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Medicare Maine
November 27, 2012 at 5:31 am

This is very good step by Obama because he covers all people by different coverage plans of medicare.

October 27, 2012 at 9:51 am

The "improvement standard" is outrageous and should be immediately dumped. Not everyone is going to "improve" when faced with a devastating illness, but they will continue to need care as they face a negative prognosis. The "improvement standard" is inhumane. Thank you, Mr. President, for your support of its dissolution. Once again, you have shown you have a heart.

October 27, 2012 at 1:24 am

I WISH that individuals with chronic health conditions COULD get assistance under Medicare. I have fibromyalgia, chronic fatigue syndrome, have had cancer three times, and now have been diagnosed with adrenal fatigue syndrome whose cause is long-term stress due to illness and/or abuse AND due to the chemotherapy medications I took. I'm so tired all of the time, and I've requested assistance from every organization that will supposedly assist and am told each and every time they're out of funds. I wish I could work so that I can pay for the prescriptions and physician copays as well as food--much less the alternative treatments not covered by insurance, but that are the only ones that help with the pain. The Medicare advantage plan I signed up with last year PROMISED me that all my medications were on their formulary--even sent a list--and on January 1, suddenly had an entirely new formulary with more than half of my meds no longer covered. Under the new health-care, I 'earn' too much disability each year--a grand total of $7/year--to qualify for extra help, which in the past 2 years has cost me over 1/2 of my income for Medicare parts A,B&D, copays, donut hole coverage! Additionally, my state dropped a large group of us from TennCare on some technicality called the 'Davies case'--I have no energy due to my medical conditions, and my medical team tells me over and over to avoid stress--how can I win? I hope they help some of us out--and SOON!
Maybe we should run for Congress--after one 2-year session in office, they 'retire' with lifetime pension and health care--yet there's no money for a cost of living increase for people on Social Security. They've certainly voted themselves COLA's every single year, above and beyond any inflation.
When you have the chance to vote this year, remember who is supporting individuals with chronic illnesses and those who aren't--use your vote to show them how your life is affected by theirs!

October 26, 2012 at 4:22 pm

This is really amazing. This is a REALLY BIG DEAL for my family -- it's been an issue for my daughter and I (we both have Ehlers-Danlos Syndrome) in getting ongoing physical therapy, because we're not going to "improve" beyond a certain point, but we need access to PT to maintain our current condition and to strengthen the muscles around our joints to compensate for the defective collagen in our ligaments, because doing that helps prevent joint injuries.

Please, please, PLEASE let this go through!!