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A major change is coming to Medicare

A lawsuit settlement will end a Medicare policy that deprives chronically ill people of needed care.

By Karen Datko Oct 25, 2012 12:00PM

Senior woman on wheelchair looking out of window with blinds © Design Pics, Don Hammond, Design Pics, Getty ImagesHere's a Medicare rule I didn't even know existed until a lawsuit settlement dealt it a death blow last week: Medicare will not pay for skilled nursing care or therapy for patients who are not expected to get better.


That's right. It doesn't matter if the skilled care or therapy would make your life less miserable or slow your downhill slide. Think of the special care needed for those with Alzheimer's or Parkinson's or chronic lung disease.


That's going to change. The Los Angeles Times explains: "Under the terms of the settlement -- expected to be approved by a federal judge in Vermont in coming months -- Medicare would not deny skilled nursing care and various forms of therapy for beneficiaries, regardless of their prognosis."


The U.S. Department of Health and Human Services called the settlement a mere clarification of the rules and downplayed the impact.


But others say this is a huge development. The New York Times, which broke the story about the lawsuit settlement, said tens of thousands could expect to benefit. Other say it could help hundreds of thousands of Medicare recipients.


The New York Times said: "Under the agreement, which amounts to a significant change in Medicare coverage rules, Medicare will pay for such services if they are needed to 'maintain the patient's current condition or prevent or slow further deterioration,' regardless of whether the patient's condition is expected to improve."

According to The Associated Press:

"Those who stand to benefit include not only people with intractable conditions like Alzheimer's, multiple sclerosis, Parkinson's and chronic lung disease. Those who are growing weaker because of advancing age, placing them at greater risk of falls and other problems, also could be helped."

The class action includes more than 10,000 Medicare patients whose claims for skilled nursing care and therapy were denied before the suit was filed. But no one knows how many Medicare recipients have simply gone without these services because they were told that Medicare wouldn't pay for them and they couldn't afford the cost themselves.


Also unknown is the financial impact to Medicare, already a large drain on the federal budget. But paying for improved care now could reduce more costly treatment and hospital stays later on. 


Another odd aspect to this case is that the rule that's being rewritten -- the so-called "improvement standard" -- isn't in the law that created Medicare nearly a half century ago or in government regulations. It's spelled out in a Medicare manual and in the rules used by private contractors hired by Medicare to decide which claims are paid and which are not.


Who all stands to benefit after the judge approves the settlement? Medicare is a government health insurance program for those 65 and older and younger people with disabilities.


Have you or someone in your family been denied coverage under Medicare's improvement standard?


More on MSN Money:


Oct 25, 2012 2:52PM

I would rather waste the money here then of overseas. As long as one US citizen need help the rest of the world can go to hell. If we can't afford to help ourselves we can't afford to help anyone else including being the world’s police force.

Oct 25, 2012 2:42PM

First the truth. Do you think active and retired senior senators and congessmen and presidents DON'T get whatever care they or their family members need?

Doesn't  logic show that a senior cared for in their home by a trained, well paid care giver is tremendously LESS expensive then care in a hospital? Billions less! over the next 10-20 years. Would not training these care givers create hundreds of thousands of jobs?  In the next 10-20 years over 1/4 of our citizens will be over 65.

Now the real truth, where are the compassionate, republicans and democrats that believe that all Americans deserve the dignity and care. We all know someone in our family, a friend, who does or will need care.

Oct 25, 2012 6:48PM

I really don't care that it is a "drain" on the Federal budget.  We can stop spending money frivolously on other social issues and giving money to other countries and help our own.  Also, we can stop giving freebies to the "illegals" and send them home where they belong until they come here the legal way.  I am really tired of the bureaucrats, 

Oct 25, 2012 5:30PM

My Father is in a Skilled Nursinf Facility and as great medical insurace but it won't pay for his skilled nursing because he has alzheimers and doesn't show emouh improvement with the physical and occupational therapy. So his savings is now being drained at a rate of over $200 per day for his care until he qualifies for medicaid.

 Such a shame to worek for everything and pay for good insurance to be denied coverage for a stupid rule of interpitation.

Oct 25, 2012 2:51PM

I would rather waste the money here then of overseas. As long as one US citizen need help the rest of the world can go to hell. If we can't afford to help ourselves we can't afford to help anyone else including being the world’s police force.

Oct 25, 2012 5:33PM

Skilled nursing care and physical therapy should be covered under your heath insuance, but it isn't jsut because the insuance companies don't want that responsibility.


Skilled nursing is heathcare, cover it.....

Oct 25, 2012 6:59PM
Just this last month Medicare cared very well for My Mother In law.  Her kidneys were failing, Medicare paid for a beautiful hospice care for her, I    pray that they do not take away this benefit for the elderly on short time table of life.
Oct 25, 2012 6:32PM
This is just the start of our downhill slide into Socialism. Big Government only cares about themselves. The Hell with everyone else
Medicare needs a "pull your own plug," clause, that lets people die with dignity, if they so choose.  Forcing people to live in excruciating pain, or with no physical or mental control, is cruel and unusual punishment.  In 2008, I asked them to put me down.  The doctors refused.  Now, I do nothing 24/7, at the peoples expense.  Life is overrated and overvalued.
Oct 25, 2012 7:57PM

My Mother-in-Law was denied skilled nursing care (unless the difference was paid out of pocket), but fortunately we were able to get her covered under Hospice Care, a much better solution and more dignified way to be treated


Oct 25, 2012 8:27PM
I was FORCED to pay into medicare since it started even though sometimes I couldn't afford regular insurance.  I paid in MANY, MANY YEARS.  Since I have PRE-PAID all these years, I SHOULDN'T HAVE TO PAY ONE THIN DIME.  However THE SOCIALIST LIBERALS think EVERYBODY deserves medicare whether they paid in or not.  Same goes for Social Security.  IF YOU DIDN'T PAY IN AND YOU ARE RECEIVING BENEFITS, YOU ARE A LEECH AND A THIEF.
Oct 25, 2012 1:40PM

Where has the author of this piece been?  If she isn't knowlegeable about Medicare policies, why is she chosen to present an article on this policy, which has been in place for years, and is, like most Medicare policy, a complex issue.  There are clearly rationale, and humane benefits from this change in policy. Maitenance of function and prevention of further decline are desirable objectives, but because of the "self-pilot" nature of much of Medicare's payment methods, this change will lead to much abuse. People who view therapy as a paid-for exercise club or social event will try to take advantage of the new policy.  Medicare will have to design policies that require evidence the therapy helps achieve these desirable objectives, just as it now requires that evidence of improvement is present.  This will not be easy, as EVERYONE in my age group (78) is declining in one way or another. By the way, my wife is an amputee in a wheel chair (routine knee replacement gone bad) who has had lots of therapy in the past two years.  This new policy will surely raise Medicare costs further, just when how to reduce those costs is central to the political debate.  I am a retired health policy analyst, if you couldn't tell. 


Oct 25, 2012 7:23PM
Another little spoken of tidbit is that Seniors will be paying MORE under OBAMACARE for less in the next several years.  MEDICARE monthly outlays are going form around $97/month now to around $240/month in 2014.  Funny how the campaign is not speaking about this. 
Oct 25, 2012 3:13PM
The number one denier of payments and procedures by FAR is Medicare, not some "evil" insurance company.   Sorry brain dead sheeple.   Palin was right.   There are built in panels whose entire purpose is to deny access to health care.   Call them what you will, but when you or your loved one is denied the newest chemotherapeutic agent, you might call it a death panel.
Oct 25, 2012 6:09PM
So the man or woman who is 80 yr old and has less than 6 months to live due to terminal illness should be given physical therapy to help cure what? Many of them just want to be left alone to die as they wish.
That rule that denied Medicare coverage in skilled nursing homes to those who wouldn't be expected to get better was rarely applied because the nursing home generally made the determination as to whether or not it thought it could help you,  but I'm still glad they struck it down.  The way it works is that I think you get the first 90 days of your coverage in a skilled nursing home covered by Medicare in full.  After that I think that your 20% supplemental policy picks up the next 90 days, or you have to pay it yourself if you don't have a supplemental policy.  However, in all cases the nursing home has to be a skilled nursing home (one where you go for rehabilitation) rather than just a retirement type of nursing home.
Oct 25, 2012 1:43PM
Oct 25, 2012 6:26PM
On the one hand it would seem (at least on the surface), to be a good thing.  On the other hand, how are we going to pay for this?  And before y'all start screaming about reducing defense spending, we only spend about 4% of our money on defense in this country.  More than 10 times that is already spent on entitlement programs.  Something's gotta be done.
Oct 25, 2012 6:11PM

thanks obama  yes hes throwing granny&grandpa under the bus.


Oct 25, 2012 3:35PM

The government already covers Long Term Care. State Medicaid begins after the personsl assets are used up because the government can't afford $3500 per month on the low side per beneficiary until the that person has used up their own funds. And the State programs are funded or subsidized by the Federal Government. Doing the math at 10,000 known denied claims means an additional 35 million dollars per month from the tax coffers, and that's before opening the flood gates for the mass population. Medicare just can't afford that, and the tax payers can't support it.

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