After the settlement of a landmark class-action lawsuit this week, Medicare will soon begin paying more often for physical, occupational and other therapies for large numbers of people with certain disabilities and chronic conditions such as MS.
While the reach of change following the ruling is still uncertain, advocates hope that Medicare will soon pay for many forms of therapy that it did not always cover before. For people with MS, this may mean more approval for treatments for spasticity and gait training to prevent falls.
Pending approval by a federal judge, the settlement would end a lawsuit that accused Medicare of allowing the contractors that process its claims to use an “improvement standard” over the last few decades. To the Center for Medicare Advocacy and the many other organizations that joined the suit, that standard seemed to call for cutting off physical, occupational and speech therapy, and some inpatient skilled nursing for many people who had reached a plateau in their treatment.
Medicare is supposed to pay for reasonable treatment of an illness or injury as long as a doctor has prescribed it. For the sort of in-home care that this week’s settlement may affect the most, a doctor must have certified that you are, in fact, homebound and have prescribed treatment that only a skilled practitioner can provide. (The “skilled practitioner” rule keeps Medicare from paying for assistance with everyday activities like bathing and dressing.)
The settlement agreement does not describe itself as an expansion of Medicare coverage. But it does state that the Centers for Medicare and Medicaid Services will revise the manuals their contractors use to make clear that coverage “does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy but rather on the beneficiary’s need for skilled care.”
The settlement also specifies that skilled care can qualify for Medicare coverage even if it merely maintains someone’s current condition or prevents or slows further deterioration. Certain patients who have had claims rejected will be able to resubmit them.
It is anticipated to take a couple of months before the judge approves the settlement, and then a year or more until the Medicare billing contractors get the newly clarified manuals.
Even so, some patient advocates see no reason for people not to demand coverage that maintains their condition or slows deterioration right now, given that Medicare was supposed to be paying for it all along.