Big, good changes are coming!
If you or a loved one needs skilled services such as nursing, occupational therapy, physical therapy or speech pathology, you may have been denied coverage by Medicare, or a provider may have declined to serve you unless you paid out of pocket.
You would have been refused because you were unable to show that you were regaining function or improving. For those with degenerative conditions such as Alzheimer’s, Parkinson’s, or simply in the last stages of life, improvement is not an option. But, we still need services to maintain our capabilities, to slow the progress of the condition, or simply to live with more dignity and comfort.
Now, Medicare covers this!
As a result of an important court ruling, Jimmo v Sebelius, Medicare no longer requires improvement. Medicare now pays for these services depending “upon an individualized assessment of the beneficiary’s medical condition and the reasonableness and necessity of the treatment, care or services in question.” Services that could be handled with non-skilled personnel (like a home health aide) are not covered.
This is big news because many more people will now be able to get the coverage they need.
This is fairly recent change. Not all providers know about it, and some Medicare employees may still apply the old standards.
What are the keys to getting this coverage?
- If you have been denied coverage in the past, revisit it. If your service provider says “no”, show them the Centers for Medicare and Medicaid Services (CMS) circular announcing the change.
- Study up! Read the circular for clues about what is covered, and for guidance about how you can improve the chances that you will get coverage.
- If Medicare itself has denied coverage, appeal it.
- Remember, you must demonstrate a clear need for skilled services. Non-skilled services are not covered.