As many of you with loved ones requiring significant medical care may know, the Medicare board has had a longstanding practice of requiring a likelihood of medical or functional improvement before a beneficiary could qualify to receive coverage for skilled nursing or therapy services, whether institutional or home-based. This practice has left many care recipients in a lurch, because at a certain point the patient may reach a plateau where no further “improvement” is expected, but continued care or therapy is still necessary. Often, this affects people with chronic or deteriorating conditions requiring care, such as Alzheimer’s, Parkinson’s, multiple sclerosis, and traumatic brain injury, just to name a few.
Without Medicare coverage, such patients with “non-improving” conditions were often left with only three options: 1) pay for the care out-of-pocket, 2) forego care entirely, or 3) move into a nursing home in order to qualify for government financial assistance.
But help may soon be on the way. As a result of a nationwide class-action suit and an agreement from the Obama administration to clarify the Medicare requirements, Medicare may soon be opening the doors to the tens of thousands who previously had been turned away and left without coverage for care based on a less than positive “improvement” prognosis.
If this settlement goes through and becomes practice, then the coverage requirement will no longer be “improvement” but “maintenance.” Accordingly, Medicare will cover services if they are needed to “maintain the patient’s current condition or prevent or slow further deterioration.” This could provide a huge relief to many patients, as well as their families and other caregivers.
For a more detailed discussion of the proposed settlement and its likely impact, take a look at a recent article in The New York Times titled “Settlement Eases Rules for Some Medicare Patients.”
For more information about this or for answers to your other elder care planning questions, please contact us at Peak Legal Group.
Reference: The New York Times (October 22, 2012) “Settlement Eases Rules for Some Medicare Patients”