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Settlement in Medicare Payment Rules Case

The vast majority of community members would prefer to “age in place” instead of moving into a long-term care facility or nursing home. Living in one’s own home comes with clear benefits regarding individual comfort, freedom, and familiarity. However, there are obviously times when living at home is impossible and skilled nursing care is a necessity. The line between when the close care is mandatory and when it is not can sometimes be tricky to delineate. Many families have likely battled with one another over these issues. Does a loved one need to move into a different living environment?

Fortunately, advances in medicine and technology have made great strides in allowing more care than ever before to be received at home, without the need to move into a skilled nursing facility or a hospital. This often means that more elderly and individuals with disabilities than ever before might be able to live longer in their own homes. However, there is one complication to this extended at-home care: how is it getting paid for?

A few families have significant means and might be able to provide all the necessary care out of pocket. But the reality is that many families rely on Medicare and Medicaid support for these long-term caregiving issues. That means that specific rules created by these programs regarding what will be covered and when have very real implicatons on the lives of the hundreds of thousands of families in this situation. At times, advocates for seniors and those with disabiltiies are forced to engage in legal battles with these government entities if they feel that rules are not applied correctly or fairly to the detriment of community members.

Medicare Payment Rules
For example, the New York Times recently reported on the settement of a case filed on behalf of those with chronic conditions, including many elderly individuals and those with serious disabilties. The specific focus of the suit was Medicare rules that had been around for quite some time and required beneficiaries to show a “likelihood of medical or functional improvement” before receiving payment support for necessary care like therapy services or even skilled nursing home care. The hurdle of meeting that “likelihood” test was often high, meaning residents were denied the support they needed to pay for the care they required via the Medicare program.

A class-action lawsuit filed by elder care advocates challenged that rule and, as outlined in the story, recently reached a settlement with federal officials. Per the terms of the settlement Medicare will now pay for necessary support in order to “maintain the patient’s current condition or prevent or slow further deterioration.” This seems logical as, in many cases, the best medical plan available is to keep one’s condition stable, even when long-term reversals of past harm might not be realistic.

In speaking on the matter, the senior care advocate and attorney involved in the dispute noted that, “As the population ages and people live longer with chronic and long-term conditions. […] [T]he government’s insistence on evidence of medical improvement threatened an ever-increasing number of older and disabled people.”

In other words, after this settlement the rules will better match the actual needs of the patients and not random “likelihood of improvement” rules that often just denied the sickest patients the care that they needed.

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