Medicare No Longer Denies Care To Seniors “Not Responding” To Treatment

March 31, 2014

The New York Times called it a “quiet sea change.” The Centers for Medicare & Medicaid Services calls it “Change Request 8458.” Regardless of what it’s called, a relatively unpublicized update to the Medicare policy manual made in January 2014 will have a profound impact on millions of Americans who suffer from chronic diseases that are progressive and for which certain types of care can only maintain a patient’s condition.

In other words, the update makes it clear that improvement is not necessary to receive Medicare coverage for skilled care.

The update was a long time coming. The process began back in 2011 when Glenda Jimmo, along with five other Medicare beneficiaries and seven national organizations (including the National Multiple Sclerosis Society, the Parkinson’s Action Network, and the Alzheimers Association) took Health and Human Services director Kathleen Sebelius to court for adopting “an unlawful and clandestine standard to determine whether Medicare beneficiaries are entitled to coverage.”

This standard reduced or outright denied coverage for services that were not actively making the patient better. Plaintiffs argued that people “not expected to improve” were being treated as “less worthy” of coverage. Proof was in language in the manual that described people in this category as needing “maintenance services only” or as patients who had “plateaued.”

Jimmo and the other Medicare recipients won their case in December 2013, leading to the manual updates in January 2014. An excerpt from the change order explained the intent of the change: “to clarify that coverage of skilled nursing and skilled therapy services… does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.”

This change marked a victory for Medicare recipients struggling to get coverage for care outside the bounds of purely “improvement-based” treatment. What’s most important is that people who have these conditions – Alzheimer’s, Multiple Sclerosis, and Parkinsons, just to name a few – need to know about this as it is hugely important to them and their quality of life.

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