We Told You So…

November 2, 2010 at 6:14 pm Leave a comment

The New York Times recently printed an article by Robert Pear entitled “Medicare Standards are Too Strict, 2 Courts Find.”

We’ve been telling people that for years.

The Times article refers to two decisions, Anderson v. Sebelius and Papciak v. Sebelius, both regarding the Medicare “Improvement Standard.”  For anyone not familiar, this is an arbitrary rule of thumb which essentially says that if the beneficiary won’t improve, Medicare won’t cover certain services.

The Improvement Standard has been used for years by Medicare contractors to improperly deny coverage.

However, per these two recent decisions, Medicare must adhere to the law as written, and pay for services if they are needed to maintain a person’s condition or to prevent deterioration of the person’s condition.   The courts stated that Medicare beneficiaries do not have to prove that their condition will improve, as the government generally contends.

The rulings are potentially significant for many people with chronic conditions and disabilities like multiple sclerosis and Alzheimer’s disease; conditions which, by their very nature, simply will not improve. In the words of one judge, patients “need not risk a deterioration of [their] fragile health” to justify continuation of coverage for skilled care.

Center for Medicare Advocacy Director of litigation Gill Deford acted as co-counsel in one of the two cases.  The Center has launched a campaign to end the Improvement Standard, and these decisions represent a significant victory.

Entry filed under: Improvement.

Vote! Our NY Times Letter to the Editor – Improvement Standard Impacts Coverage and Care

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Health Policy Expertise

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November 2010


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