Expanded Medicare coverage for chronic conditions now in effect

Seniors who have chronic illnesses and disabilities can now get Medicare coverage for skilled nursing and therapy 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 conditions.

Earlier this year, the government agreed to settle a class action lawsuit over this issue. That settlement has now been approved by a federal court – and what’s more, the settlement has been made retroactive to January 18, 2011, so if you were denied coverage for services after that date, you might be able to go back and re-apply for coverage.

The settlement applies to care in a skilled nursing facility as well as to home health care and outpatient therapy.

For decades, Medicare had a “rule of thumb” that coverage of these services was available only if they were likely to lead to an improvement in the patient’s condition. Treatments that weren’t likely to lead to improvement were considered “custodial care,” which Medicare doesn’t cover.

But this “rule of thumb” never actually appeared anywhere in the Medicare laws, the government now admits.

The change is effective as of right now. As a result, patients who have “plateaued” in their treatment but still need the assistance of a skilled professional such as a nurse or therapist are now 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 such as eating, dressing, and bathing – and this kind of 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.

Seniors who applied for Medicare benefits after January 18, 2011 and were denied due to the “rule of thumb” – and whose appeal period has expired – will be able to have those denials reviewed under the new standard. The government is still determining exactly how this review process will work.

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