The ASHA Leader - April 2013 - (Page 18)

P O L I C Y A N A LY S I S Medicare Must Cover Services That Maintain Function A recent settlement eliminates the need for “functional progress” and allows patients with progressive conditions to receive maintenance services. BY MARK K ANDE R Medicare must cover services that prevent deterioration and maintain functional levels—not just those that result in functional progress— according to a settlement recently accepted by a federal judge. Under the change, Medicare may not deny speech-language pathology services (and occupational and physical therapy) simply because the beneficiary shows no functional progress. This change represents a major expansion of Medicare coverage, which has long defined “reasonable and necessary”—a criterion for coverage—to include the expectation that the patient’s condition will improve significantly in a reasonable period of time. This settlement will likely have a ripple effect across some state Medicaid programs and also could affect private insurance coverage decisions. Experts anticipate that the resulting increased services to patients with chronic diseases— such as Parkinson’s or multiple sclerosis—will decrease Medicare expenditures by reducing inpatient hospitalization and the need for other costly health care services. The settlement of Jimmo v. Sebelius, approved in late January, requires the Centers for Medicare and Medicaid Services to revise its policy manuals by January 2014 to reflect the elimination of the “Medicare Improvement Standard,” which requires patients to show functional progress to continue to receive rehabilitation services. The services must require skilled care. 18 APRIL 2013 | THE ASHA LE ADER The settlement specifies that outpatient services are covered, as are those provided in skilled nursing facilities and inpatient rehabilitation facilities and by home health agencies. The settlement also applies to Medicare Advantage plans, which are private insurers that contract with practitioners to manage Medicare benefits. This clarified scope of coverage is also expected to apply to accountable care organizations, but CMS has not yet issued this guidance. It’s unclear whether nonfunctional progress therapy minutes for Medicare Part A patients in skilled nursing facilities will count toward their total therapy minutes, and thus their rehabilitation status, for billing purposes. The original case involved plaintiff Glenda Jimmo, a 71-year-old Vermont resident who had a belowthe-knee amputation and suffered from a number of other chronic conditions. The suit was initiated Medicare may not deny speech-language pathology services (and occupational and physical therapy) simply because the beneficiary shows no functional progress. by five plaintiff organizations— the Parkinson’s Action Network, Paralyzed Veterans of America, National Multiple Sclerosis Society, National Committee to Preserve Social Security and Medicare, and American Academy of Physical Medicine and Rehabilitation— that were joined by five plaintiff Medicare patients. The Center for Medicare Advocacy and co-counsel Vermont Legal Aid filed the classaction lawsuit against the U.S. Department of Health and Human Services in January 2011. Re-review of claims The settlement allows the “rereview” of therapy services claims denied for lack of significant functional progress after Jan. 17, 2011. Several conditions, however, apply: • The patient must seek the rereview on his or her own behalf; providers and suppliers may not request it. • The claims should not have been paid by other third-party payers (excluding Medicaid). • The original denial must have been based solely on the maintenance standards and have been independent of any other reasons for denial. Patients pursuing re-review may need documentation from providers, including speech-language pathologists, that indicates medically necessary services were rendered. ASHA warns that despite beneficiaries’ and advocates’ pressure on providers to seek coverage immediately for maintenance therapies,

Table of Contents for the Digital Edition of The ASHA Leader - April 2013

The ASHA Leader - April 2013
Contents
Inbox
From the President
News in Brief
Blogjam
People
In the Limelight
Overheard
Policy Analysis
At a Glance
On the Job
Bottom Line: Who Pays for Autism and Communication Skills Services for Young Adults?
Make It Work: Dominate Your IEP Data
School Matters: Opt for Affordable, Low-Tech Intervention With Resonance Disorders
Academic Edge: Are New York State CSD Programs Ready for Autism? Is Anyone?
On the Pulse: No Teeth, No Dentures: Is a Regular Diet Possible?
App-titude: Apps for High Schoolers With Autism
From the Journals
Spectrum of Opportunities
Facing Up to ASDs
After Commencement, Clarity
ASHA Elections
Speaking of Associates
ASHA News
State Spotlight
American Speech-Language- Hearing Foundation
Careers/Classifieds
Posted
First Person on the Last Page

The ASHA Leader - April 2013