Proposed CMS settlement expands Medicare coverage for chronic patients

In a proposed settlement in a nationwide class-action lawsuit, the Centers for Medicare & Medicaid Services clarified rules in which Medicare will cover patients to maintain their conditions rather than show marked improvements. If approved, the settlement would relax the long-standing burden on chronically ill and disabled patients to demonstrate clinical improvements, The New York Times reported.

In January 2011, the lawsuit representing more than 10,000 Medicare beneficiaries--including the plaintiffs of the National Multiple Sclerosis Society, the Parkinson's Action Network, Paralyzed Veterans of America and advocacy group, the National Committee to Preserve Social Security and Medicare--claimed in Jimmo v. Sebelius that existing Medicare coverage rules unfairly denied beneficiaries of skilled care, such as nursing and therapy services.

"If you have a chronic condition, by definition, you are not improving," lead attorney Gill Deford with the Center for Medicare Advocacy, told CBS News. "Our view is that Medicare regulations were intended to allow people to maintain their health status. They don't have to show they are getting any better. The point is to allow them not to get any worse, if possible."­

Although CMS, at one point, argued no such "improvement standard" existed, Medicare officials later said in a separate lawsuit in Pennsylvania "there must be an expectation that the beneficiary's condition will improve materially in a reasonable and generally predictable period of time," the NYT noted.

However, with the settlement, CMS clarifies that the so-called "improvement standard" would be a "maintenance standard," in which Medicare will pay to "maintain the patient's current condition or prevent or slow further deterioration." The Medicare Benefit Policy Manual also would be revised to clarify that skilled nursing facility, home health and outpatient therapy coverage "does not turn on the presence or absence of a beneficiary's potential for improvement but rather on the beneficiary's need for skilled care."

If the federal court in Vermont certifies the claims denied before Jan. 18, 2011, Medicare could reexamine thousands of claims.

While government officials expect the change will increase costs for Medicare, the NYT noted, other experts contend the settlement will expand physical therapy and home healthcare, thereby avoiding potentially costly hospitalizations.

For more information:
- read the NYT article and editorial
- read the CBS News article
- see the lawsuit details and information from the Center for Medicare Advocacy
- check out the settlement agreement (.pdf)

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