If you, or a loved one, depend on Medicare for ongoing care of a chronic or degenerative disease, you may be familiar with the Medicare Improvement Standard.

Medicare is health national insurance for people over age 65, the disabled, or those with end stage renal disease. For decades, the Medicare Improvement Standard meant that coverage for physical, occupational and speech therapy and some inpatient skilled nursing was denied by contractors processing claims for many people who had reached a plateau in their treatment, that is to say, for those who were not improving.

Medicare is supposed to pay for reasonable treatment as long as a doctor has prescribed it. For in-home care, a doctor must have certified that you are, in fact, homebound and have prescribed treatment that only a skilled practitioner can provide. This “skilled practitioner rule” keeps Medicare from paying for assistance with everyday activities like bathing and dressing.

Consider the case of Glenda, she is 76 and rendered disabled by diabetes. She is both blind and has suffered amputation of a leg and several toes. She was the lead plaintiff in the case that led to the settlement, and under the Medicare Improvement Standard, had been denied coverage of the skilled care she needed due to the fact that her condition was chronic and did not improve. This unofficial policy has been frustrating to many. It is often painfully obvious that those suffering chronic or degenerative diseases will not and cannot improve. But, the kind of skilled care covered by the Medicare Improvement Standard settlement can stabilize or slow the progression of such diseases. These patients can now prevent painful and costly complications.

The Medicare Improvement Standard settlement requires the Centers for Medicare and Medicaid Services to clarify to their contractors that home and nursing home therapy and nursing services for Medicare beneficiaries are not dependent “on the presence or absence of a beneficiary’s potential for improvement from the therapy (and nursing care), but rather on the beneficiary’s need for skilled care.” This language also pertains to outpatient therapy services. This clarified policy is know as the “maintenance coverage standard.”

The Center for Medicare Advocacy, co-counsel for the Plaintiffs, stresses that the new standard applies now, and that Medicare patients denied coverage under the old “medicare improvement standard” should advocate for themselves and appeal those denials.

It is important to remember that this Medicare Improvement Standard settlement does not affect the need for long-term care planning. Without careful planning you may still have to pay for years in a nursing home when you can no longer handle basic tasks of daily living and staying in your home is no longer practical.

If you, or a loved one, would like more information about long-term care planning contact us. Proficient in Estate Planning, Elder Law and Long-Term Care/Medicaid (MassHealth) Planning, Attorney Kristina Vickstrom can help you understand your rights and any remedies that may be available to you.