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Many beneficiaries and providers have questions about obtaining Medicare and Medicare Managed Care 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 Managed Care plans. The rules for determining what services a beneficiary can receive, and what Medicare will pay for, should be the same for both delivery systems.
A chronic condition requiring skilled care services can take many forms and is not limited to a particular set of disease, diagnosis, or disabling conditions.
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 a medical condition or the functioning of a body part; or
- Slow or prevent the deterioration of a medical condition or body part.
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 for chronic, long-term conditions, including maintenance and rehabilitative therapies and services, disease management and access to specialties.
- Make sure your physician writes a detailed prescription and treatment plan for health care, maintenance and/or rehabilitative services you need. The plan of treatment should be reviewed frequently. Specifically, a Medicare home health care plan should be reviewed and re-certified every 62 days.
- If you are told by your health care provider or Managed Care plan 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 you are in a Managed Care plan, make sure you understand the procedures of the plan for filing complaints about a service denial or a termination of care. If you decide to challenge the termination or denial, provide the plan with as much information as possible about your need for Medicare covered skilled care services. Ask your doctor to write in support of necessary services.
- If you are not getting the care you need, discuss it with your physician and health care providers. If services or coverage are denied, file and appeal.
- Seek help in getting Medicare coverage for your health care you need by contacting your doctor, your local Health Insurance Counseling Program, legal assistance program, or Area Agency on Aging. These organizations should be listed in your phone book. They can also be located through the national ELDER LOCATOR program by calling 1(800)677-1116.
Medicare, including a Medicare Managed Care plan, should look at your overall medical condition as set forth in your 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.
Medicare should give great weight to the medical judgment of your treating physician, specialists, therapists, and others directly involved in providing your health care services.
The Medicare program is required to look at your total condition and health care needs, not just a specific diagnosis, or your 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.