Expanding Medicare Coverage

Medicare coverage is about to expand, perhaps substantially, for people with chronic conditions and disabilities. The rule for a long time has been that skilled nursing and therapy services were covered by Medicare only if there was a likelihood that the care would result in a medical or functional improvement. Care that simply helped people do things they couldn’t do on their own or that maintained function wasn’t covered.

The administration now plans to change this rule as part of a settlement of a class-action lawsuit. That can be good news for those who can use the care, which includes both home care, skilled nursing home care, and physical therapy. But it also is likely to increase Medicare’s costs substantially and bring the program to its financial demise even faster than currently forecast.

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.

Federal officials agreed to rewrite the Medicare manual to make clear that Medicare coverage of nursing and therapy services “does not turn on the presence or absence of an individual’s potential for improvement,” but is based on the beneficiary’s need for skilled care.

Judith A. Stein, director of the nonprofit Center for Medicare Advocacy and a lawyer for the beneficiaries, said the proposed settlement could help people with chronic conditions like Alzheimer’s disease, multiple sclerosis, Parkinson’s disease, stroke, spinal cord injuries and traumatic brain injury. It could also provide relief for families and caregivers who often find themselves stretched financially and personally by the need to provide care.