Advocacy Group Challenges Major Medicare Coverage Barrier

The Center for Medicare Advocacy is launching a new initiative to eliminate the Medicare "Improvement Standard," which requires that Medicare beneficiaries be able to improve in order to qualify for coverage. For decades Medicare beneficiaries, particularly those with long-term, debilitating conditions and those who need rehabilitation services, have been denied necessary medical and rehabilitative care based on this standard, which conflicts with federal law.

With support from The Atlantic Philanthropies, the Center for Medicare Advocacy will begin a focused effort to eliminate the Improvement Standard in Medicare policy and practice. The effort will include advocacy with the Obama administration, litigation if needed, and a multi-faceted education campaign.

"The insistence that people must be able to get better unfairly restricts access to Medicare coverage and necessary health care," says the Center. "Although the Improvement Standard conflicts with the law, it has become deeply ingrained in the system and ardently followed by those who provide care and those who make coverage determinations throughout the health care continuum. Beneficiaries are told Medicare coverage is not available if their underlying condition will not improve, if they have 'plateaued,' are not likely to improve, or if they need 'maintenance care only'. As a result it keeps people with debilitating, chronic conditions from receiving the care they need. This practice persists although the Medicare Act does not require improvement as a precondition to coverage for illness or injury. Further, the federal regulations state that 'restoration is not to be the deciding factor' in making Medicare coverage determinations."

The Center notes that the people most affected by this barrier include people with Multiple Sclerosis, Alzheimer's disease, ALS (Lou Gehrig's disease), spinal cord injuries, diabetes, Parkinson's disease, hypertension, arthritis, heart disease, and stroke.

The Center offers the following example based on a real case.

Mrs. P, 68 years old, was diagnosed with ALS five years ago. She now needs a wheelchair, cannot stand on her own, needs assistance to move from bed to wheelchair, and is losing the use of her arms and hands. Mrs. P has been receiving home health care including nursing twice per month, OT twice per month and daily home health aide services. Despite her need for this care, Mrs. P's Medicare Advantage plan and home health agency informed her that Medicare would no longer cover her home care because she is chronic and "stable in her disease state," and will not improve. She was informed that she therefore does not need skilled care a prerequisite for Medicare home health coverage.

The Center filed a complaint in federal district court and obtained a restraining order requiring that Medicare grant coverage and that home health care be provided as ordered by Mrs. P's physician.

Contact the Center at improvement@medicareadvocacy.org if you or someone you know has had problems obtaining Medicare coverage, necessary health care, or rehabilitative services because the patient was said to be chronic, stable, not likely to improve, or in need of "maintenance services only."

For more on the Improvement Standard from the Center, click here.

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