A Sea Change In Medicare Policy For Chronic Conditions

Executive Briefing | by | November 1, 2012

Monica E. Oss
Monica E. Oss

Thursday, November 1, 2012

What a difference a few words can make. The October 16 settlement by the Center for Medicare & Medicaid Services (CMS) on the Jimmo v. Sebelius case (see Advocacy Groups Sue Medicare Over Continuing Denial of Services Due to “Demonstrable Improvement” Requirement ) is a slight change in definitions – with huge implications for consumers with chronic conditions.

The Jimmo v. Sebelius case was a class action lawsuit that challenged the Medicare policy of denying coverage based on the “Improvement Standard”, meaning that patients had to show medical or functional improvement— or the potential for that improvement—before Medicare would pay for a specific service. The new settlement negates this “Improvement Standard” policy. The Center for Medicare Advocacy, Inc. reports that, following a federal judge’s approval of the settlement, “CMS will revise the Medicare Benefit Policy Manual and other Medicare Manuals to correct suggestions that Medicare coverage is dependent on a beneficiary ‘improving’.”

What does this mean for consumers? It will be easier to get services if you have a condition that may not “improve” but will be “maintained” by those services. This will affect some outpatient therapies, physical therapy, occupational therapy, speech-language pathology services, home care, and some skilled nursing home stays.

The scale of the effect of this change in policy is not yet clear. The New York Times coverage, Settlement Eases Rules for Some Medicare Patients, has reported that the numbers of patients affected could be “tens of thousands.” Some of the conditions likely affected by this policy change services include dementias including Alzheimer’s disease, multiple sclerosis, Parkinson’s Disease, stroke, spinal cord injuries, and traumatic brain injury. But the ruling may be far more expansive. Additional The New York Times coverage – What Medicare Will Cover Even if You’re Not Likely to Get Better – quotes Peter Thomas, outside counsel for the American Academy of Physical Medicine and Rehabilitation as saying “I think the settlement opens coverage up to pretty much any condition that creates functional impairment.”

The federal court approval that will put this settlement into action may not come until early 2013, and it will be at least another year before Medicare has to make the change policy and provide additional details to provider organizations that are looking to be reimbursed for these services. But this is another reason to take a look at chronic conditions with functional impairments as part of your planning process – and to reconsider investments in the range of new tools for improving cognitive functioning. As the settlement is finalized and new rules take shape, we’ll keep you updated.


Monica E. Oss
Chief Executive Officer, OPEN MINDS

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