Policy shift likely to allow more home health care access

WASHINGTON — Tens of thousands of people with chronic conditions and disabilities may find it easier to qualify for Medicare coverage of potentially costly home health care, skilled nursing home stays, and outpatient therapy under policy changes planned by the Obama administration.

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 that 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.

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Judith A. Stein, director of the nonprofit Center for Medicare Advocacy and a lawyer for the beneficiaries, said the proposed settlement could help people with chronic conditions like Alzheimer’s disease, multiple sclerosis, Parkinson’s disease, stroke, spinal cord injuries, and traumatic brain injury.

It could also provide relief for families and caregivers who often find themselves stretched financially and personally by the need to provide such care.

‘‘As the population ages and people live longer with chronic and long-term conditions,’’ Stein said, ‘‘the government’s insistence on evidence of medical improvement threatened an ever-increasing number of older and disabled people.’’

In many cases, she said, the denial of coverage led to a denial of care, because most people cannot afford to pay for these services on their own.


Neither she nor Medicare officials could say how much the settlement might cost the government, but the price of expanding such coverage could be substantial. Dr. Lynn Gerber, director of the Center for Study of Chronic Illness and Disability at George Mason University in Virginia, called the settlement ‘‘a landmark decision for Medicare recipients with chronic illness and especially those with disability.’’