The federal government’s Medicare
agency (the Centers for
Medicare & Medicaid Services or CMS) has released revisions to its program
manuals and related instructions that will make it easier for
chronically ill individuals to get Medicare coverage. The program manuals and
guidance are used by Medicare providers and contractors in determining an individual's eligibility for Medicare benefits.
The changes are intended to ensure
that Medicare eligibility determinations for Skilled Nursing Facility, Home
Health, and Outpatient Therapy are no longer dependent on the ability of the
patient to improve.
The policy
clarification should benefit tens of thousands of seniors and others with chronic
conditions and disabilities and make Medicare benefits more readily available
to pay for home health care, skilled nursing home stays and outpatient therapy.
In the past, individuals were
required to show that there was a likelihood of medical or functional
improvement before Medicare would pay for skilled nursing care and therapy
services. This was commonly referred to as the “improvement standard.” Individuals
whose condition was no longer improving were denied therapy that might be required for them
to maintain their current level of functioning.
Under the new clarification, Medicare
will pay for such skilled services if they are needed "to maintain the
patient’s current condition or prevent or slow further deterioration" even if
the patient’s condition is not expected to improve.
According to CMS:
No “Improvement Standard” is to be
applied in determining Medicare coverage for maintenance claims in which
skilled care is required. Medicare has long recognized that
even in situations where no improvement is expected, skilled care may
nevertheless be needed for maintenance purposes (i.e., to prevent or slow a
decline in condition). For example, the longstanding SNF level of care regulations,
specify that the “. . . restoration potential of a patient is not the deciding
factor in determining whether skilled services are needed. Even if full
recovery or medical improvement is not possible, a patient may need skilled
services to prevent further deterioration or preserve current capabilities. . .
.
Maintenance therapy.
Even if no improvement is expected, under the SNF, HH, and OPT coverage
standards, skilled therapy services are covered when an individualized
assessment of the patient’s condition demonstrates that skilled care is
necessary for the performance of a safe and effective maintenance program to
maintain the patient’s current condition or prevent or slow further
deterioration. Skilled maintenance therapy may be covered when the particular patient’s
special medical complications or the complexity of the therapy procedures
require skilled care. CMS, MLN
Matters® Number: MM8458 Revised (emphasis in original).
This clarification is already effective. CMS is now embarked on a campaign to
educate contractors and providers that Medicare determinations for Skilled
Nursing Facility, Home Health, and Outpatient Therapy must be based on the need
for skilled care – not on the ability of the patient to improve.
Revisions are a Big Deal
I think that the demise of the
improvement requirement is a pretty big deal. Seniors and other individuals with
chronic conditions are now much more likely to receive the care they need to maintain
their functional levels. And qualifying for therapy means that related services
(e.g. the cost of room and board in a nursing home) may also be covered by Medicare.
The change will also benefit other
participants in the elder care support network, including Medicare funded providers and
even the Commonwealth of Pennsylvania.
- Providers, including Skilled Nursing Facilities (nursing homes that participate in the Medicare program), benefit because they are now able to provide the therapies and care their patients need and do so for a longer period of time. They also benefit financially by receiving reimbursements at what is normally a much higher Medicare rate (compared with Medicaid).
- States are benefited because keeping nursing home residents on 100% federally funded Medicare longer effectively delays their need for Medicaid benefits. To the extent that a nursing home stay is paid for by Medicare (100% federal dollars), the expenditure of Medicaid dollars (approximately 47% state money currently in Pennsylvania) is delayed, reduced, or avoided entirely. See my earlier posting: “A letter to the Governor – How to Reduce State Expenditures on Nursing Home Care.”
The CMS
Transmittal for the Medicare Manual revisions, with a link to the revisions
themselves, is posted at: http://tinyurl.com/qggk7j4.
Further information and self-help materials
are available from the Center
for Medicare Advocacy.
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