Posts published by Susan Jaffe

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A Quiet ‘Sea Change’ in Medicare

By Susan Jaffe

Ever since Cindy Hasz opened her geriatric care management business in San Diego 13 years ago, she has been fighting a losing battle for clients unable to get Medicare coverage for physical therapy because they “plateaued” and were not getting better.

“It has been standard operating procedure that patients will be discontinued from therapy services because they are not improving,” she said.

Glenda Jimmo at home in Lincoln, Vt., in 2012. She was the lead plaintiff in a lawsuit over whether Medicare should pay for treatment for people whose underlying conditions were not likely to improve. Paul O. Boisvert for The New York Times

No more. In January, Medicare officials updated the agency’s policy manual — the rule book for everything Medicare does — to erase any notion that improvement is necessary to receive coverage for skilled care. That means Medicare now will pay for physical therapy, nursing care and other services for beneficiaries with chronic diseases like multiple sclerosis, Parkinson’s or Alzheimer’s disease in order to maintain their condition and prevent deterioration.

But don’t look for an announcement about the changes in the mail, or even a prominent notice on the Medicare website. Medicare officials were required to inform health care providers, bill processors, auditors, Medicare Advantage plans, the 800-MEDICARE information line and appeals judges — but not beneficiaries.

Ms. Hasz said she was shocked when she heard the news. “This is a sea change,” she said.

The manual revisions were required in the settlement to a class-action lawsuit filed in 2011 against Kathleen Sebelius, the secretary of health and human services, by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of four Medicare patients and five national organizations, including the National Multiple Sclerosis Society, Parkinson’s Action Network and the Alzheimer’s Association. The settlement affects care from skilled professionals for physical, occupational or speech therapy, and home health and nursing home care, for patients in both traditional Medicare and private Medicare Advantage plans.

“It allows people to remain a little healthier for a longer time and stay a little bit more independent,” said Margaret Murphy, associate director at the Center for Medicare Advocacy. And it eases the burden on families who “are scrambling to take care of their loved ones,” she said.

The change may have the most far-reaching impact on seniors who want to avoid institutional care. People with chronic conditions may be able to get the care they need to live in their own homes for as long as they need it, Ms. Murphy said, if they otherwise qualify for coverage.

Existing eligibility criteria haven’t changed. Although seniors probably won’t hear the words “plateau” or “improvement” when coverage is denied, they can still lose coverage for reasons other than a lack of improvement.

For nursing home coverage, you must have a doctor’s order prescribing skilled nursing home care (not custodial care), and you must have spent three consecutive midnights in the hospital as an admitted patient (observation days don’t count). Limits on the duration of Medicare nursing home coverage remain the same.

Physical and speech therapy ordered by a doctor and provided in a nursing home or an outpatient facility by a skilled professional are subject this year to a $1,920 therapy cap. Providers can get an automatic exception to the cap for medically necessary treatment until costs reach $3,700. At that point, another exception is possible after Medicare reviews medical documentation. (Occupational therapy is provided to patients with separate $1,920 and $3,700 caps, with the same exceptions.)

For home health coverage, you must have a doctor’s order for intermittent care — every few days or weeks — provided by a skilled professional for outpatient therapy, social work services or a visiting nurse.

The therapy caps do not apply in the home setting so long as the patient is “homebound,” and that doesn’t necessarily mean confined to bed. Someone who is homebound requires “considerable and taxing effort to leave home,” Ms. Murphy said, and cannot do so without another person or a wheelchair, walker, cane or other device.

Beneficiaries receiving skilled services at home are also eligible for home health care aides for assistance with bathing, dressing and other daily activities.

The settlement also establishes a special “re-review” procedure for claims that were denied in the past three years solely because patients were not improving or because their care was intended to maintain their condition.

Officials have posted a form beneficiaries can use to request reimbursement if they paid for care themselves. The form must be submitted by July 23, 2014, for claims with a final denial dating from Jan. 18, 2011, through Jan. 24, 2013.

Requests for review of denials received Jan. 25, 2013, through Jan. 23, 2014, are due Jan. 23, 2015. If the claim is denied again, a Medicare spokesman said, beneficiaries may appeal through the regular appeals process.

But what if, despite the settlement, your provider or a Medicare representative still says you can’t continue treatment only because you are not improving?

First, point them to Medicare’s online fact sheet about the settlement, which clearly says, “Coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required.” (And let us know what happens.)

If that doesn’t work, contact your state Quality Improvement Organization for help filing an expedited appeal. Ask the doctor who ordered treatment for a letter of support.

If you receive the treatment and pay for it yourself (or are on the hook for the bill), Ms. Murphy suggests asking the provider to bill Medicare. Then you should appeal the denial by following the instructions provided on your Medicare summary notice or in the appeal decision letter. The Center for Medicare Advocacy’s website provides more details.

If all else fails, email the center’s lawyers at improvement@medicareadvocacy.org. They are meeting regularly with Medicare officials to monitor compliance with the settlement and will tell the agency about coverage denials prohibited in the settlement. Despite Medicare’s efforts to get the word out, the center still receives complaints every week from people denied treatment only because they are not getting better.

Fighting ‘Observation’ Status

By Susan Jaffe

Every year, thousands of Medicare patients who spend time in the hospital for observation but are not officially admitted find they are not eligible for nursing home coverage after discharge.

A Medicare beneficiary must spend three consecutive midnights in the hospital — not counting the day of discharge — as an admitted patient in order to qualify for subsequent nursing-home coverage. If a patient is under observation but not admitted, she will also lose coverage for any medications the hospital provides for pre-existing health problems. Medicare drug plans are not required to reimburse patients for these drug costs.

The over-classification of observation status is an increasingly pervasive problem: the number of seniors entering the hospital for observation increased 69 percent over five years, to 1.6 million in 2011.

The chance of being admitted varies widely depending on the hospital, the inspector general of the Department of Health and Human Services has found. Admitted and observation patients often have similar symptoms and receive similar care. Six of the top 10 reasons for observation — chest pain, digestive disorders, fainting, nutritional disorders, irregular heartbeat and circulatory problems — are also among the 10 most frequent reasons for a short hospital admission.

Medicare officials have urged hospital patients to find out if they’ve been officially admitted. But suppose the answer is no. Then what do you do?

Medicare doesn’t require hospitals to tell patients if they are merely being observed, which is supposed to last no more than 48 hours to help the doctor decide if someone is sick enough to be admitted. (Starting on Jan. 19, however, New York State will require hospitals to provide oral and written notification to patients within 24 hours of putting them on observation status. Penalties range as much as $5,000 per violation. )

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Dental Coverage on the Insurance Exchanges

By Susan Jaffe

Older adults and their caregivers have complained for years that Medicare, which now covers 52 million Americans, does not provide dental benefits.

“It’s a huge problem,” said Barbi Jo Stim, a geriatric care manager at Jewish Family and Children’s Services of the East Bay, a social service agency in Berkeley, Calif. “If older adults can’t afford the dental work they need, they can’t chew, they don’t get the nutrition they need and that can affect their overall health.”

Dental assistant Albert Hernandez helped X-ray the teeth of a nursing home resident in San Antonio, Tex. Jennifer Whitney for The New York Times

For some adults with Medicare, the online insurance exchanges created by the Affordable Care Act may offer an alternative (assuming they become functional in the near future). True, the vast majority should not purchase health insurance on the exchanges. But unless they are enrolled in a private Medicare Advantage managed care plan that already includes dental benefits, Medicare beneficiaries are legally permitted to purchase dental plans on the exchanges.

“There is nothing in the Affordable Care Act that prohibits the sale to Medicare beneficiaries of standalone dental plans on the exchanges,” said Leslie Fried, policy and programs director at the National Council on Aging in Washington, D.C.

Still, there are drawbacks. The standalone dental plans for adults can set annual dollar limits on coverage and don’t have to comply with caps on out-of-pocket spending mandated by the A.C.A. for health plans. Insurance premium subsidies and assistance with out-of-pocket expenses are not available. And in some states, exchange dental plans can reject adult applicants because of pre-existing conditions.

The choices vary dramatically by state.

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Q & A: Medicare and the Insurance Exchanges

By Susan Jaffe

Shirley Mierzejewski was “very upset” when she found out her Medicare health insurance premiums will nearly double next year.

“I cannot afford that, I cannot,” said Ms. Mierzejewski, 77, who lives in Euclid, Ohio, and works part time as a receptionist at a local college. She has a private Medicare Advantage policy from Anthem, which provides drug and medical coverage.

“So I started thinking about the marketplaces,” she said, referring to the online insurance exchanges created by the Affordable Care Act. “Maybe I could find something cheaper there.”

But after attending a Medicare meeting this month at the Euclid Senior Center, she learned that the plans available on the exchanges are not intended for most people with health insurance — and that includes those with Medicare.

While thousands of Americans are trying to sign up for insurance on the exchanges, Medicare counselors like Semanthie Brooks, who spoke at the meeting Monday in Euclid, are trying to steer seniors away. They worry that Ms. Mierzejewski and other older adults may not realize that Medicare is a pretty good deal compared to exchange policies and may try to buy one anyway.

Exchange plan enrollment began on Oct. 1 and runs through March. The enrollment period for next year’s Medicare Advantage and prescription drug plans — many offered by the same companies selling marketplace coverage — starts Tuesday and ends Dec. 7.

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Finances & Legalities

Therapy Plateau No Longer Ends Coverage

By Susan Jaffe
Glenda Jimmo, of Lincoln, Vt., was one of the plaintiffs in the class-action lawsuit challenging the cutoff of Medicare payments for physical therapy and other treatments for patients who were not improving. Paul O. Boisvert for The New York Times

Ellen Gorman, 72, a New York psychotherapist, can’t walk very far and gets around the city mainly by taxi, “which is really expensive,” she said. Twice since 2008 her physical therapy was discontinued because she wasn’t progressing. But after a knee replacement last year, she is getting physical therapy again, exercising with her therapist and building up her endurance by walking in the hallway of her Manhattan apartment building.

“Before this, I was getting weaker and weaker, and I just kept caving in,” she said.

Because of an action by Congress and a recent court settlement, Medicare probably won’t cut off Ms. Gorman’s physical therapy again should her progress level off — as long as her doctor says it is medically necessary.

Congress continued for another year a little-known process that allows exceptions to what Medicare pays for physical, occupational and speech therapy. The Medicare limits before the exceptions are $1,900 for physical and speech therapy this year, and $1,900 for occupational therapy.

In addition, the settlement of a class-action lawsuit last month now means that Medicare is prohibited from denying patients coverage for skilled nursing care, home health services or outpatient therapy because they had reached a “plateau,” and their conditions were not improving. That will allow people with Medicare who have chronic health problems and disabilities to get the therapy and other skilled care that they need for as long as they need it, if they meet other coverage criteria.

The settlement is expected to affect thousands, and possibly millions, of Medicare beneficiaries with chronic health problems like Parkinson’s or Alzheimer’s disease, stroke, multiple sclerosis and spinal cord injuries. It could also help families, as well as the overburdened Medicare budget, delay costly nursing home care by enabling seniors to live longer in their own homes.

“Under this settlement, Medicare policy will be clarified to ensure that claims from providers are reimbursed consistently and appropriately and not denied solely based on a rule-of-thumb determination that a beneficiary’s condition is not improving,” said Fabien Levy, a spokesman for the U. S. Department of Health and Human Services, which includes the Medicare program. Read more…

More Time to Enroll in Medicare If You Live in Storm Areas

By Susan Jaffe

Medicare beneficiaries battered by Hurricane Sandy have one fewer problem to worry about: Federal officials have extended the Dec. 7 deadline to enroll in a private medical or drug plan for next year for those still coping with storm damage.

The Centers for Medicare and Medicaid Services “understands that many Medicare beneficiaries have been affected by this disaster and wants to ensure that all beneficiaries are able to compare their options and make enrollment choices for 2013,” Arrah Tabe-Bedward, acting director for the Medicare Enrollment and Appeals Group, wrote in a Nov. 7 letter to health insurance companies and state health insurance assistance programs.

Beneficiaries hit by the storm can still enroll after the Dec. 7 midnight deadline if they call Medicare’s 24-hour information line: 1-800-MEDICARE (1-800-633-4227). Representatives will be able to review available plans and complete the enrollment process over the phone.

“We are committed to giving people with Medicare the information and the time they need to make important decisions about their coverage,” a Medicare spokeswoman, Isabella Leung, said in an e-mail message. Medicare officials have not set a new deadline but have encouraged beneficiaries to make their decisions soon if possible.

People currently in a plan will be automatically re-enrolled for next year in the same plan.

The extra time also applies to any beneficiaries who normally get help from family members or others to sort through dozens of plans, but who have been unable to do so this year because they live in areas affected by the storm. Neither beneficiaries nor those who provide them assistance will be required to prove that they experienced storm damage.

“This is a really important recognition by CMS to accommodate Medicare enrollees affected by Hurricane Sandy,” said Leslie Fried, director for policy and programs at the National Council on Aging, an advocacy group in Washington.

After the hurricane, the Obama administration declared Connecticut, New Jersey, New York and Rhode Island “major disaster areas,” according to the Federal Emergency Management Agency. In addition, FEMA issued emergency declarations for parts of Delaware, the District of Columbia, Maryland, Massachusetts, New Hampshire, Pennsylvania, Virginia and West Virginia.

More than four million older people in those states are enrolled in drugs-only plans, and more than 2.8 million have Medicare Advantage policies, which includes medical and drug coverage.

Susan Jaffe is a writer for Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

A Benefits Statement You Can Read

By Susan Jaffe

Belle Likover, a 92-year-old seniors advocate in Shaker Heights, Ohio, led the Ohio Department of Aging’s advisory council last year, and she is not easily deterred by government mumbo jumbo. Still, she struggled to understand the summary of payments she recently received from Medicare after a five-day hospital stay.

“I don’t understand these codes,” she said. “There are five different doctors listed, and I have no idea who some of them are.”

There’s good news for anyone who, like Mrs. Likover, has ever tried to decipher one of the inscrutable statements, called Medicare summary notices, mailed quarterly to roughly 36 million beneficiaries. Starting next year, officials will begin using a new consumer-friendly format; it’s already available online at www.mymedicare.gov. The mysterious procedure codes are still there, but an easy-to-understand explanation of each service in larger type replaces the descriptions containing baffling abbreviations and medical terms.

The change comes with an incentive for reading more carefully: Medicare will offer rewards of up to $1,000 for tips that lead to uncovering fraud. Last year, Medicare recovered a record $4 billion in fraudulent payments with help from people who reported questionable charges.

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