April 29, 2014 / 1:06 PM / 6 years ago

New Medicare coverage of long-term care off to a rocky start

CHICAGO (Reuters) - A physical therapist visits Robert Klaiber, 78, weekly to provide a special type of massage that helps alleviate his symptoms from Parkinson’s disease. Klaiber’s wife, Diane, was under the impression Medicare wouldn’t cover the therapy, which costs $500 or more a month. But earlier this month a neighbor noticed an announcement in a retirement newsletter.

A patient waits in the hallway for a room to open up in the emergency room at Ben Taub General Hospital in Houston, Texas, July 27, 2009. REUTERS/Jessica Rinaldi

“He showed me this item talking about an important change in the Medicare rules,” she says. “I didn’t know anything about it.”

Klaiber had tripped across important information about the settlement of a class action that should make Robert’s therapy eligible for Medicare coverage. Under the 2012 settlement of Jimmo v. Sebelius, the U.S. Department of Health and Human Services agreed to relax Medicare’s requirements for coverage of skilled nursing and therapy services in institutional or home care settings.

Prior to the settlement, Medicare’s policy was to cover skilled nursing care only when patients had demonstrated medical potential to improve. Starting this year, the key criterion for coverage is a demonstrated need for skilled care - even if the patient isn’t expected to improve. That means patients already enrolled in Medicare Part A (hospitalization) who need care to maintain their current condition but aren’t likely to improve now qualify for Medicare’s standard benefits.

That should be good news for the Klaibers, a retired couple living in Marstons Mills, Massachusetts, on Cape Cod. But Diane Klaiber instead finds herself embroiled in a coverage dispute with Robert’s healthcare provider that underscores the rough start for the new Medicare rules.

Medicare has published new rules spelling out the changes, and an education campaign aimed at healthcare providers began in January. Diane talked with the nurse from Robert’s home healthcare provider, to no avail.

“She didn’t know anything about it, but said she’d take it back and talk with the office staff about it. They said they didn’t have any information on it, didn’t know how to bill Medicare for this kind of care or what this new rule means for them.” She’s been going back and forth with the provider since then, with no resolution in sight.

The class action was filed by the Center for Medicare Advocacy and Vermont Legal Aid, on behalf of four Medicare patients, and several national patients’ rights groups, including the Parkinson’s Action Network and the National Multiple Sclerosis Society.

The settlement requires Medicare to communicate the changes to healthcare providers and insurance companies, but not beneficiaries. Klaiber was lucky enough to hear about it from her neighbor, but many people aren’t aware of the change, says Judith Stein, director of the Center for Medicare Advocacy.

Many healthcare providers haven’t grasped it, either, she adds. “We’re getting a lot of inquiries from people who have had problems getting access to care. There’s still a great deal of education that healthcare providers need to get on this. Many of them just aren’t aware of what they need to do to proceed.”

Many Americans think Medicare covers long-term support and services, but the benefits are limited. Medicare pays for a stay of up to 100 days in a nursing or rehabilitation home following a related hospital admission, with a $152 daily co-pay after 20 days of care. Medicare also covers skilled home health care, such as physical therapy or nursing services, if a physician certifies that the care is necessary.

Medicare Part A covers up to 100 home visits following a hospital stay. For patients who need care in their homes, Medicare Part B covers care without a prior hospitalization with no limits on visits and no co-payments for services, and a 20 percent co-payment for durable medical equipment.

The Jimmo settlement means Medicare now covers patients who need ongoing skilled care that isn’t expected to lead to long-term improvement. That can make a meaningful difference for patients like Klaiber, a retired researcher at Bell Laboratories who has suffered from Parkinson’s for eight years. He also suffers from Lewy body, a form of dementia associated with Parkinson’s. He has received massage therapy since a hospitalization late last year that was followed by a 40-day stay in a skilled nursing facility.

Diane Klaiber, a 64-year-old retired librarian, says taking care of her husband is a nearly full-time occupation. “People have no idea how much work it is just to manage all the paperwork,” she says.

The Klaibers have commercial long-term care insurance, which helps cover the cost of the full-time home caregiver they employ but doesn’t pay for home-based skilled care. Out-of-pocket monthly costs (not covered by insurance) for Robert’s care usually hit $4,500, including caregiving, prescription drugs and various supplies, which comes out of the couple’s retirement savings.


The new rules apply in cases where your doctor indicates that you (or a loved one) need skilled nursing care or therapy to maintain current health. If you encounter problems with a healthcare provider that doesn't understand how to handle a Medicare claim under the new rules, consult the Center for Medicare Advocacy's page of self-help packets (bit.ly/RVi92w).

The Medicare Rights Center also offers free counseling by phone (1-800-333-4114), and free one-on-one help with Medicare claims is available from the State Health Insurance Assistance Program (SHIP), a network of non-profit Medicare counseling services. Use this link to find the SHIP program in your state (bit.ly/1iqKgeZ)

(The opinions expressed here are those of the author, a columnist for Reuters.)

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Editing by Douglas Royalty)

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