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Thread: Wow - Medicare coverage for maintenance PT and more

  1. #1

    Wow - Medicare coverage for maintenance PT and more

    Are you guys familiar with the ongoing class action lawsuit for those of us on Medicare with chronic medical conditions, like SCI?


    http://www.nytimes.com/2012/10/23/us...-patients.html

    In a proposed settlement of a nationwide class-action lawsuit, the administration has agreed to scrap a decades-old practice that required many beneficiaries to show a likelihood of medical or functional improvement before Medicare would pay for skilled nursing and therapy services.

    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.

    Wow - this is absolutely huge. By my read, that means that all of us will get coverage for PT/OT indefinitely - to maintain our level of function and continue to make improvements over time.

  2. #2
    You are so right, this is HUGE! I didn't know a thing about it. Thank you so much for posting!

  3. #3
    Quote Originally Posted by smashms View Post
    Yeah they say it now but I just started therapy again and I had to get financial aid thru the hospital because I have gone over my visit limit for the year. Some new thing they just started in October however they made it retroactive, sucks!! And I only have Medicare!

    Hopefully this will help you very soon, since it is a decision for Medicare. It will be finalized this week, so I suspect the changes will come in over time.

    I was also wondering how this will affect the yearly caps. It is possible they will keep the caps. If you can find a hospital based rehab program, often they can apply for waivers to extend beyond the caps. Private rehab programs can't do this.

  4. #4
    Wow, this is big.
    I wonder if this will also help the people who are currently using wound vac therapy. My understanding is that Medicare will only cover the costs of the wound vac, if there is a certain amount of continued improvement in the wound/s, during a specific amount of time. I hope this helps these people as well. That would be great! Thanks for posting.

  5. #5
    Also - once Medicare makes a change like this, other private insurance companies will need to follow suit.

  6. #6
    Other carriers will have to follow suit, nut remember they can drag it out.

    It is a huge win, but hopefully it will be used the way it was intended- to help those who need it, without clogging up the System. It might take a little while to get enough people in place to meet everyone's needs.

    But it is a HUGE win.

    CKF

  7. #7
    Senior Member
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    i wonder if the beyond theraphy that shephards offers that is not covered by medicare would be now?

  8. #8
    I think that we will have to see what exactly is covered. My guess is that they may become a little less restrictive over time. Who knows?
    CKF

  9. #9
    Time will tell. Remember with any approved changes, then comes more committees, then more discussion, then internal agency meetings, then back to Congress for regulation and monitoring. I served under 2 different Presidential administrations as the Disability Rights Advocate/Coordinator to the President himself.... Its a long process to put everything in place typically. But, a huge win and just in time for the election......
    Disclaimer: Answers, suggestions, and/or comments do not constitute medical advice expressed or implied. Please consult your attending physician for medical advise and treatment. In the event of a medical emergency please call 911.

  10. #10
    Quote Originally Posted by russianrob View Post
    Time will tell. Remember with any approved changes, then comes more committees, then more discussion, then internal agency meetings, then back to Congress for regulation and monitoring. I served under 2 different Presidential administrations as the Disability Rights Advocate/Coordinator to the President himself.... Its a long process to put everything in place typically. But, a huge win and just in time for the election......
    Where are we going to get the money for these programs? OT and PT are rarely needed especially if no progress is being made.Stretching can be done by family member or attendent.

    With record number of baby boomers retiring,Medicare is being stretched to the limit.

    Russian Rob,what did you accomplish serving the President? We don't need more ramps,we need more jobs? Why are there fewer people in chairs working now than in 1990?

    Can you describe one of your typical work days and your qualifications?I have 2 disabled friends with EEOC complaints that have not been resolved in 2.5 years? Why the unacceptable delays?

    Where do you work now? Please ask Obama to speak out on the 74% illegitimate birth rate in black community. If the black man would take responsibility for his multiple kids by multiple women then the severely disabled could get more PCA care.Same with illegals and the 50% illegitimate birth rate among Hispanics.

    I'm a white Republican C/8 quad post 44 years and worked a full time job 36 years. I'm taxed out. Since you have such an important job,I'm sure you have private insurance like me.How much do you pay out of pocket each year for medical expenses?How much is your copay on a new wheelchair?
    For those of you who want others to pay more taxes for you,refuse your Social Security raise.

    I'm been through 12 surgeries and several pressure sores so I have an understanding of problems associated with SCI and other severe impairments.Home Health agencies are draining Medicare with unnecessary therapy.Medicaid is eating up state budgets due toblack sperm doners and poor immigrants most here illegally.

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