The federal government’s Medicare agency (the Centers for Medicare & Medicaid Services – CMS) has released revisions to its program manuals and related instructions that will make it easier for chronically ill individuals to get Medicare coverage. The program manuals and guidance are used by Medicare providers and contractors in determining an individual’s eligibility for Medicare benefits.

The changes are intended to ensure that Medicare eligibility determinations for Skilled Nursing Facility, Home Health, and Outpatient Therapy are no longer dependent on the ability of the patient to improve.

The policy clarification should benefit tens of thousands of seniors and others with chronic conditions and disabilities and make Medicare benefits more readily available to pay for home health care, skilled nursing home stays and outpatient therapy.

In the past, individuals were required to show that there was a likelihood of medical or functional improvement before Medicare would pay for skilled nursing care and therapy services. This was commonly referred to as the “improvement standard.” Individuals whose condition was no longer improving were denied therapy that might be required for them to maintain their current level of functioning.

Under the new clarification, Medicare will pay for such skilled services if they are needed “to maintain the patient’s current condition or prevent or slow further deterioration” even if the patient’s condition is not expected to improve.

According to CMS:

No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims in which skilled care is required. Medicare has long recognized that even in situations where no improvement is expected, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). For example, the longstanding SNF level of care regulations, specify that the “. . . restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities. . . .

Maintenance therapy. Even if no improvement is expected, under the SNF, HH, and OPT coverage standards, skilled therapy services are covered when an individualized assessment of the patient’s condition demonstrates that skilled care is necessary for the performance of a safe and effective maintenance program to maintain the patient’s current condition or prevent or slow further deterioration. Skilled maintenance therapy may be covered when the particular patient’s special medical complications or the complexity of the therapy procedures require skilled care. CMS, MLN Matters® Number: MM8458 Revised (emphasis in original).

This clarification is already effective. CMS is now embarked on a campaign to educate contractors and providers that Medicare determinations for Skilled Nursing Facility, Home Health, and Outpatient Therapy must be based on the need for skilled care – not on the ability of the patient to improve.

Revisions are a Big Deal

I think that the downfall of the improvement standard is a pretty big deal. Seniors and other individuals with chronic conditions are now much more likely to receive the care they need to maintain their functional levels. And qualifying for therapy means that related services (e.g. the cost of room and board in a nursing home) may also be covered by Medicare.

The change will also benefit other participants in the elder care support network, including Medicare funded providers and even the Commonwealth of Pennsylvania.

Further information and self-help materials are available from the Center for Medicare Advocacy.