A proposed settlement of a massive class-action lawsuit could completely change the way that one rule is carried out in the Medicare system, making it easier for those who are disabled and chronically ill to qualify for Medicare coverage.
The settlement, which is expected to be approved by a federal judge in Vermont in the next few months, would make it so that Medicare cannot deny skilled nursing care and other forms of therapy for patients regardless of whether they are expected to get better or not, reports The L.A. Times.
Medicare is currently required by law to cover healthcare services that are “reasonable and necessary for the diagnoses or treatment of illness or injury,” but it doesn’t currently cover custodial care.
This means that a lot of nursing care that is performed by nonskilled aides who do things like helping seniors eat and get dressed are not covered.
Medicare, in practice, has also denied coverage for people whose condition was not likely to improve under what has become known as the “improvement standard.”
Under the improvement standard, someone who has Medicare but also has multiple sclerosis or Parkinson’s disease would be denied coverage for something like physical therapy because, while it would help keep them stable or prevent declines in their health, it would not improve their health.
Judith Stein, executive director of the Center for Medicare Advocacy, who represented the plaintiffs in the case, stated:
“These individuals have been denied Medicare coverage and access to medically necessary care for decades. We have finally been able to eliminate this illegal, harmful, unfair application of the law.”
Reuters notes that under the settlement for the lawsuit Jimmo v. Sebelius, the US Department of Health and Human Services agreed to relax the requirements of Medicare for coverage of skilled nursing and therapy services in institutional and home care settings.
The settlement’s focus is on these skilled nursing care and home-based services, though its impact on patients will be wide. Forty-six percent of Medicare beneficiaries have at least three chronic conditions, according to a survey by the Kaiser Family Foundation. Eight percent of them currently use home health services, though that number is expected to rise because of the settlement. Stein added:
“With access to some basic therapies, many of these patients may well be able to avoid nursing and hospital care. The settlement is a victory for people who need care, and it will save money for states and the federal government who otherwise would be paying for services that shouldn’t be necessary.”
Following court approval of the Medicare settlement, the program will have one year to implement the changes and also to educate healthcare providers about them. Patients who believe they qualify for coverage under the settlement’s terms are being urged to push for the services right away by submitting claims to Medicare.