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People with chronic conditions and long-term illnesses are too often denied Medicare coverage on the grounds that they will not improve, need "maintenance services only," have "plateaued" or are "chronic and stable". Taken together, these reasons are referred to here as the Medicare "Improvement Standard." Because Medicare is often the sole or primary insurance for this population, Medicare coverage denials often result in the loss of necessary health care.

This is frequently true, for example, for people with arthritis, Parkinson's disease, Alzheimer's disease, ALS, HIV, and Multiple Sclerosis (MS). Because their underlying illnesses will not be cured, these individuals are frequently denied Medicare coverage for an array of health care services including home care and physical therapy.  These services are often key, not only to the health and welfare of the individuals, but also to the ability to access Medicare coverage for other necessary health services.

Since the Center for Medicare Advocacy's founding in 1986, individuals with chronic conditions have comprised a disproportionate share of our clientele; they need advocacy to obtain Medicare coverage for critically important health and rehabilitative care. This Weekly Alert presents a very brief summary of the Medicare coverage which can be available to people with chronic conditions.

MEDICARE COVERAGE STANDARDS

Medicare coverage can be available for health care and therapy services even if the patient's condition is unlikely to improve. Chronic conditions should not be a barrier to Medicare coverage, nor should any particular diagnosis, including arthritis, as coverage decisions should not be based on diagnosis, treatment norm or any other "rule of thumb." Instead, Medicare coverage decisions should be based on an individual assessment of the person's need for the care or services in question. The questions should be "does the individual meet the coverage criteria particular to the services in question, and require skilled care", NOT "will he/she improve." Further, coverage for medically necessary services for chronic, long-term conditions should be equally available in both the traditional Medicare program and in Medicare managed care plans.  The rules for determining what services a beneficiary can receive, and what Medicare will pay for, should be the same for both delivery systems.

SKILLED COVERAGE REQUIREMENTS

The Medicare program often requires an individual to need "skilled" care in order to trigger coverage for both that care and related services. This is true, for example, to obtain coverage for home care, skilled nursing facility care, and outpatient therapies. Skilled services are those services provided by (or under the supervision of ) technical or professional personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech pathologists, and audiologists. Services must be those that are not ordinarily performed by non-skilled personnel. Medicare law recognizes that skilled services may include those which are needed to:

• Maintain the status of a medical condition or of the patient's functioning; or

• Slow or prevent the deterioration of a medical condition or of the patient's functioning.

It is not necessary that the individual's underlying condition improve for Medicare coverage to be available.

HOW SHOULD MEDICARE COVERAGE DECISIONS BE MADE?

Medicare, including Medicare private plans, should look at the patient's overall medical condition as set forth in the medical record.  The Medicare program is required to look at the patient's total condition and health care needs, not just a specific diagnosis, or the patient's chance for full or partial recovery.  Diagnosis alone should not determine one's right to Medicare coverage.  Further, coverage should not be denied simply because the patient's condition is chronic or expected to last a long time. For example, if it is medically necessary, Medicare coverage can be available for:

• Physical (and other) therapy to maintain the patient's condition
• Observation and assessment of the patient's condition; and
• Management of the patient's care plan.

Medicare should give great weight to the medical judgment of the treating physician, specialists, therapists, and others directly involved in providing the patient's health care services. 

PRACTICAL TIPS FOR DEALING WITH MEDICARE COVERAGE

• Understand basic rules for providing Medicare covered services for chronic, long-term conditions, including maintenance and rehabilitative therapies and services. For information on coverage in all settings visit the Center for Medicare Advocacy's website: www.medicareadvocacy.org. Click on the "Improvement Standard" link.

• Make sure the individual's physician writes an order and treatment plan for the health care or rehabilitation services needed by the individual.

• Remember that the Medicare Conditions of Participation require that an individual's care should not be terminated or reduced without an order from his/her physician.

• If a Medicare beneficiary is told that health care or rehabilitation services are to be terminated, request a written notice. The notice should contain the reason for the termination, and should explain the steps necessary to contest the decision.  This is needed to appeal a Medicare denial.

• To challenge a coverage denial, provide as much information as possible about the need for the care.  It is very helpful to have a written statement from the individual's doctor and other health care providers (physical therapists, etc.) explaining the need for the health care services in question.

• Seek help in getting Medicare coverage for necessary health care by contacting the individual's doctor, and the state's health insurance assistance program (SHIP).  To find the name and number of the local SHIP call 1(800) MEDICARE or visit www.shiptalk.org.   

• Information about Medicare, related issues, and resources is available on line at the Center for Medicare Advocacy's web site: www.medicareadvocacy.org.   For additional help, contact us at improvement@medicareadvocacy.org.

RECENT DEVELOPMENTS

As a result of focused efforts by the Center for Medicare Advocacy and a grant from the Atlantic Philanthropies Foundation, new efforts are underway to eliminate the unfair and illegal Improvement Standard and its impact on denying access to Medicare coverage and necessary care – including for people with chronic conditions.

Among other activities, Center attorneys recently met with leaders from the Department of Health and Human Services and the Centers for Medicare & Medicaid Services (CMS) to address these issues. We seek clarification from CMS that the need to improve is not a valid reason to deny Medicare coverage. We are hopeful that CMS will take definitive steps to inform its agents, at all levels of decision-making, and in all care settings, that this standard is never to be the deciding factor in making a Medicare coverage determination.

If you or someone you know has been adversely affected by Medicare requiring improvement in order to gain access to coverage, please write us at improvement@medicareadvocacy.org.