New Medicare coverage of long-term care off to a rocky start

Judith Stein, director of the Center for Medicare Advocacy.

Judith Stein, director of the Center for Medicare Advocacy.

A physical therapist visits Robert Klaiber, 78, weekly to provide a special type of physical therapy that helps alleviate his symptoms from Parkinson’s disease. Klaiber’s wife, Diane, was under the impression Medicare wouldn’t cover the therapy, which costs $500 or more a month. But earlier this month a neighbor noticed an announcement in a retirement newsletter.

“He showed me this item talking about an important change in the Medicare rules,” she says. “I didn’t know anything about it.”

Klaiber had tripped across important information about the settlement of a class action that should make Robert’s therapy eligible for Medicare coverage. Under the 2012 settlement of Jimmo v. Sebelius, the U.S. Department of Health and Human Services agreed to relax Medicare’s requirements for coverage of skilled nursing and therapy services in institutional or home care settings.

Prior to the settlement, Medicare’s policy was to cover skilled nursing care only when patients had demonstrated medical potential to improve. Starting this year, the key criterion for coverage is a demonstrated need for skilled care – even if the patient isn’t expected to improve. That means patients already enrolled in Medicare Part A (hospitalization) who need care to maintain their current condition but aren’t likely to improve now qualify for Medicare’s standard benefits.

That should be good news for the Klaibers, a retired couple living in Marstons Mills, Massachusetts, on Cape Cod. But Diane Klaiber instead finds herself embroiled in a coverage dispute with Robert’s healthcare provider that underscores the rough start for the new Medicare rules.

Medicare has published new rules spelling out the changes, and an education campaign aimed at healthcare providers began in January. Diane talked with the nurse from Robert’s home healthcare provider, to no avail.

“She didn’t know anything about it, but said she’d take it back and talk with the office staff about it. They said they didn’t have any information on it, didn’t know how to bill Medicare for this kind of care or what this new rule means for them.” She’s been going back and forth with the provider since then, with no resolution in sight.

The class action was filed by the Center for Medicare Advocacy and Vermont Legal Aid, on behalf of four Medicare patients, and several national patients’ rights groups, including the Parkinson’s Action Network and the National Multiple Sclerosis Society.

The settlement requires Medicare to communicate the changes to healthcare providers and insurance companies, but not beneficiaries. Klaiber was lucky enough to hear about it from her neighbor, but many people aren’t aware of the change, says Judith Stein, director of the Center for Medicare Advocacy.

Many healthcare providers haven’t grasped it, either, she adds. “We’re getting a lot of inquiries from people who have had problems getting access to care. There’s still a great deal of education that healthcare providers need to get on this. Many of them just aren’t aware of what they need to do to proceed.”

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