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Many beneficiaries and providers often have questions about obtaining Medicare and Medicare Advantage coverage for services provided to individuals with on-going, chronic conditions.
Medicare coverage can be available for health care and therapy services even if the patient's condition is unlikely to improve.
Medicare coverage for medically necessary services for chronic, long-term conditions should be equally available in both the traditional Medicare program and in Medicare Advantage (MA) plans. The rules for determining what Medicare covers are the same for both delivery systems.
A chronic or long-term condition or disability requiring skilled services can take many forms. Medicare coverage is not limited to, or prohibited for, any particular disease, diagnosis, or disability.
The Medicare program recognizes the need for skilled care and related services for chronic, long-term conditions. For care to be covered, the patient must require skilled services which may be designed to:
- Maintain the status of an individual's condition; or
- Slow or prevent the deterioration of a condition; or
- Improve the individual's condition
Medicare coverage decisions should be based on whether the patient needs skilled careand meets any other criteria for the setting in which the required care is provided. Medicare should be equally available whether the skilled care is to maintain or to improve the underlying condition. For more information regarding coverage to maintain a person's condition, review the Center's material regarding Jimmo v. Sebelius, which confirmed these rights.
Skilled care is care which must be provided by, or under the supervision of, a qualified professional (nurse or physical, occupational or speech therapist) to be safe and effective.
Services can be provided in a variety of settings – at home, through Medicare certified home health agencies, in Medicare certified outpatient facilities, rehabilitation hospitals and centers, and in Medicare certified skilled nursing facilities.
Skilled services are those services provided by (or under the supervision of) technical or professional personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech pathologists, and audiologists. Services must be a type that are not ordinarily performed by non-skilled personnel.
- Understand basic rules for providing Medicare covered services in the care setting in which the care is provided.
- Make sure a physician writes a detailed prescription and treatment plan for the health care, maintenance and/or rehabilitative services you need. The plan of treatment should be reviewed frequently.
- If the care provider or MA plan says that your maintenance and/or rehabilitation services are to be terminated, request a written notice. The notice should contain the reason for the termination, and should explain the steps and timeliness necessary to contest the decision.
- If the individual is enrolled in an MA plan, understand the procedures of the plan for filing complaints about a service denial or a termination of care. To challenge the termination or denial of coverage, provide the plan with as much information as possible about the need for the skilled care services. Ask the doctor to write in support of necessary services.
- Seek help in getting Medicare coverage for necessary care by contacting the individual's doctor and the local Health Insurance Counseling Program, legal assistance program, or Area Agency on Aging. Information about htese resources is available through the national ELDER LOCATOR program by calling 1-800-677-1116.
- Medicare, including a Medicare Advantage plan, should look at the individual's overall condition as set forth in the medical record.
- Medicare coverage should not be denied simply because the patient's condition is chronic or expected to last a long time. "Restoration potential" is not necessary. Skilled care to maintain an individual's condition can be ordered.
- Medicare should give great weight to the medical judgment of the treating physician, specialists, therapists, and others directly involved in providing the individual's health care services.
- The Medicare program is required to look at the idividual's total condition and health care needs, not a specific diagnosis, or the chance for full or partial recovery.
- Physical therapy to maintain the patient's condition;
- Observation and assessment of the patient's condition; and
- Management of the patient's care plan.
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- For older articles, please see our article archive.