Medicare Settlement Could Help Seniors Slow Disease Symptom Progression

NEW YORK (MainStreet) — As a result of a recent a recent court settlement, Medicare beneficiaries who have a medical need for skilled care can now qualify for maintenance therapy coverage.

In Jimmo vs. Sebelius, the Center for Medicare Advocacy (CMA) claimed that contractors were inappropriately denying Medicare claims for skilled care based on an improvement standard used by physical therapists and occupational therapists. The improvement standard requires that a patient must show potential for rehabilitation.

When a patient stops showing significant improvement, Medicare will no longer pay, says Allison Simms, rehab clinical manager at Visiting Nurse Service of New York.

In the Jimmo case, the CMA argued that some Medicare beneficiaries require skilled care in order to prevent or slow further deterioration of a medical condition.

The Centers for Medicare & Medicaid Services (CMS) denied establishing an improvement standard in order for skilled care to be covered.

The settlement agreement does not expand on Medicare benefits but rather clarifies that in cases where skilled services are required in order to prevent or slow further deterioration caused by a medical condition, coverage cannot be denied due to the lack of potential for improvement or restoration, according to the CMS.

The settlement is good news for people like Terri Corcoran. In 2004, Corcoran's husband, who had been diagnosed with a degenerative neurological condition, had "plateaued" in his rehabilitation therapy and was turned down by Medicare for maintenance therapy to keep him moving in order to reduce the risk of complications.

"Medicare gave up on him many years ago," Corcoran says.

Corcoran, who is the public relations chair at Well Spouse Association, a national support group for spouse caregivers, pays for a private therapist and aides.

Patients who have chronic problems with movement, as do patients with disorders and conditions such as Parkinson's disease, Alzheimer's, muscular sclerosis, stroke and others, can benefit from maintenance therapy, Simms says, and there is no Medicare cap on skilled maintenance services as there is with rehabilitative care.

Few people with Parkinson's will improve, so they need maintenance therapy, says Amy Comstock Rick, CEO of Parkinson's Action Network. It saves Medicare money by preventing falls, so it's a good use of Medicare dollars, Comstock Rick says. "It's an ounce of prevention," she says.

The CMS has until January 23, 2014, to revise its new manual and educational campaign for providers and others.

In the meantime, Medicare beneficiaries or caregivers who run into difficulty, because their doctor or the agency providing rehabilitative services is not aware of the maintenance services that Medicare will now cover, can go to CMA's website at medicareadvocacy.org and print the appropriate the CMS factsheets and show the document to their provider, says Judith Stein, executive director of the Center for Medicare Advocacy.

--Written by S.Z. Berg, author of College on the Cheap

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