Medicare beneficiaries with degenerative diseases, such as Parkinson's, may be eligible for certain skilled care services, including speech-language pathology services, even after reaching a maintenance level of care. A proposed settlement that addresses this issue has not yet been approved by the court, but ASHA will keep its members up to date on related developments. The action is the result of a lawsuit challenging Medicare coverage policies administered by the Centers for Medicare and Medicaid Services (CMS) that deny coverage to those who are unable to show improvement. In the proposed settlement, CMS has agreed to
- revise its policy manual to state that benefits are to be based on the beneficiary's need for the care, rather than on the potential for improvement;
- inform providers, contractors, and adjudicators of the changed policy; and
- allow class members who received a denial of skilled services to have claims re-reviewed.
Currently, after a patient has plateaued in functional progress, Medicare covers only the brief training of caregivers and family in the implementation of a maintenance program. In the proposed settlement, it is expected that speech-language pathologists will be covered for rendering skilled treatment that maintains or prevents deterioration of function; however, the conditions of coverage will be known only after CMS revises its policy manual. A main contention of the lawsuit by the Parkinson's Action Network and the Center for Medicare Advocacy is that in specific cases of degenerative disease skilled therapy can help slow degeneration.
The proposed settlement will apply to inpatient and outpatient settings as well as the private Medicare Advantage programs. It is estimated the settlement will take up to 6 months to finalize in the courts, with action by CMS in a year. The implications of the court's final decision are significant and would expand the scope of coverage of therapy services for patients who will benefit from continued service regardless of the likelihood of functional improvement. More information about the specifics of the lawsuit is available at the Center for Medicare Advocacy website.
For more information, please contact Mark Kander, ASHA's director of regulatory analysis, at [email protected].