In a major change, the federal government has agreed to provide seniors who have chronic illnesses and disabilities with Medicare coverage for many services … even if those services will simply maintain the person’s present health status and aren’t likely to improve their condition.
This is very important news for people who have diabetes, heart disease, Alzheimer’s disease, multiple sclerosis, Parkinson’s disease, Lou Gehrig’s disease, arthritis, or the effects of a stroke, among other medical conditions.
Soon, these seniors may be able to obtain Medicare coverage for care in a skilled nursing facility, as well as home health care and outpatient therapy.
For decades, Medicare had a “rule of thumb” that coverage for these services was available only if they were likely to lead to an improvement in the patient’s condition. This resulted in many people with chronic illnesses being unable to obtain coverage for treatments that were critical to maintaining their health, but that didn’t promise a cure or improvement.
According to the government, treatments that weren’t likely to lead to improvement were considered “custodial care,” which Medicare doesn’t cover.
But in January 2011, a group of seniors and some elder advocacy groups brought a nationwide class action lawsuit against the government. They argued that this policy violated their rights, because the “rule of thumb” against covering such services never actually appeared anywhere in the Medicare laws.
The government tried to have the case thrown out, but recently a federal judge rejected that request and allowed it to proceed. Shortly afterward, the government agreed to settle the case by expanding Medicare coverage.
The settlement is being reviewed by the court, and it’s still unclear exactly when the policy change will go into effect. It’s also unclear whether the change will apply just to future claims or to claims going all the way back to January 2011.
Under the terms of the settlement, patients who have “plateaued” in their treatment but still need the assistance of a skilled professional such as a nurse or therapist will be eligible for all of Medicare’s standard benefits. Seniors who are enrolled in Part A, which covers hospitalizations, will be eligible for up to 100 days in a skilled nursing facility (as long as it follows a three-day hospitalization), as well as up to 100 home visits following a hospitalization. Seniors who are enrolled in Part B, which covers doctor visits and other outpatient services, are eligible for potentially unlimited home visits.
It’s not completely clear to what extent the new policy will increase Medicare coverage for dementia. Many seniors with dementia simply need custodial care – unskilled help with routine activities of daily living such as eating, dressing, and bathing – and this kind of unskilled care wouldn’t be covered under the settlement.
However, if the services of a skilled professional might delay the progress of dementia, then those services might be covered. For example, Medicare might now cover occupational therapists who specialize in helping dementia sufferers.
In addition, Medicare might also begin covering speech therapists who teach stroke and Parkinson’s patients how to regain their communications skills.