MESSAGE
| DATE | 2014-03-26 |
| FROM | Ruben Safir
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| SUBJECT | Subject: [NYLXS - HANGOUT] important news that you might have missed
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This is from the NY Times: I can't get into the details of why this is
a massive change and a complete departure from the current Obama Care
standards but it is the most important thing to have happened probably
in two months.
Lawsuites are going to start flying now
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A Quiet ?Sea Change? in Medicare By SUSAN JAFFE March 25, 2014,
5:00 am
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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. Glenda Jimmo at home in Lincoln, Vt., in 2012. She was
the lead plaintiff in a lawsuit over whether Medicare should pay
for treatment for people whose underlying conditions were not likely
to improve. Paul O. Boisvert for The New York TimesGlenda Jimmo
at home in Lincoln, Vt., in 2012. She was the lead plaintiff in a
lawsuit over whether Medicare should pay for treatment for people
whose underlying conditions were not likely to improve.
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.
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.
?It allows people to remain a little healthier for a longer time
and stay a little bit more independent,? said Margaret Murphy,
associate director at the Center for Medicare Advocacy. And it
eases the burden on families who ?are scrambling to take care of
their loved ones,? she said.
The change may have the most far-reaching impact on seniors who
want to avoid institutional care. People with chronic conditions
may be able to get the care they need to live in their own homes
for as long as they need it, Ms. Murphy said, if they otherwise
qualify for coverage.
Existing eligibility criteria haven?t changed. Although seniors
probably won?t hear the words ?plateau? or ?improvement? when
coverage is denied, they can still lose coverage for reasons other
than a lack of improvement.
For nursing home coverage, you must have a doctor?s order prescribing
skilled nursing home care (not custodial care), and you must have
spent three consecutive midnights in the hospital as an admitted
patient (observation days don?t count). Limits on the duration of
Medicare nursing home coverage remain the same.
Physical and speech therapy ordered by a doctor and provided in a
nursing home or an outpatient facility by a skilled professional
are subject this year to a $1,920 therapy cap. Providers can get
an automatic exception to the cap for medically necessary treatment
until costs reach $3,700. At that point, another exception is
possible after Medicare reviews medical documentation. (Occupational
therapy is provided to patients with separate $1,920 and $3,700
caps, with the same exceptions.)
For home health coverage, you must have a doctor?s order for
intermittent care ? every few days or weeks ? provided by a skilled
professional for outpatient therapy, social work services or a
visiting nurse.
The therapy caps do not apply in the home setting so long as the
patient is ?homebound,? and that doesn?t necessarily mean confined
to bed. Someone who is homebound requires ?considerable and taxing
effort to leave home,? Ms. Murphy said, and cannot do so without
another person or a wheelchair, walker, cane or other device.
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.
But what if, despite the settlement, your provider or a Medicare
representative still says you can?t continue treatment only because
you are not improving?
First, point them to Medicare?s online fact sheet about the
settlement, which clearly says, ?Coverage depends not on the
beneficiary?s restoration potential, but on whether skilled care
is required.? (And let us know what happens.)
If that doesn?t work, contact your state Quality Improvement
Organization for help filing an expedited appeal. Ask the doctor
who ordered treatment for a letter of support.
If you receive the treatment and pay for it yourself (or are on
the hook for the bill), Ms. Murphy suggests asking the provider to
bill Medicare. Then you should appeal the denial by following the
instructions provided on your Medicare summary notice or in the
appeal decision letter. The Center for Medicare Advocacy?s website
provides more details.
If all else fails, email the center?s lawyers at
improvement-at-medicareadvocacy.org. They are meeting regularly with
Medicare officials to monitor compliance with the settlement and
will tell the agency about coverage denials prohibited in the
settlement. Despite Medicare?s efforts to get the word out, the
center still receives complaints every week from people denied
treatment only because they are not getting better.
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