By Mark Miller
CHICAGO (Reuters) - Glenda Jimmo has had a challenging life. Blind since the age of 19, the 76-year-old Bristol, Vermont, resident is confined to a wheelchair due to disabling conditions that include a below-the-knee amputation stemming from her diabetes.
"But it's been an interesting, full life," she says. "I have four children."
Now, she's lent her name to a class action lawsuit. Its settlement, announced this week, is expected to transform the way that Medicare covers long-term care.
Jimmo requires regular skilled nursing services in her home for wound care and management of her condition. Medicare has not been paying for those services, because the program's policy was to cover skilled nursing care only when patients had a demonstrated medical potential to improve. That left patients like Jimmo, who need care to maintain their current health status, to fend for themselves.
Under the settlement of the lawsuit, Jimmo v. Sebelius, the U.S. Department of Health and Human Services has agreed to relax Medicare's requirements for coverage of skilled nursing and therapy services in institutional or home care settings.
The key criterion for coverage will be a demonstrated need for skilled care - regardless of whether there is a recovery prognosis. That means patients already enrolled in Medicare Part A (hospitalization) who need care to maintain their current condition but aren't likely to improve will qualify for Medicare's standard benefits.
Medicare already pays for a stay of up to 100 days in a nursing or rehabilitation home following a related hospital admission, with a $139 daily co-pay after 20 days of care. (Most Medigap supplemental policies will cover those co-pays.) It also covers skilled home healthcare - like physical therapy or nursing services - if a physician has certified that it 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 settlement's impact on patients will be wide, though its focus on skilled nursing care and home-based care means that it won't be broad enough to allow an elderly, demented assisted-living resident to have her or his bill paid by Medicare. Those people typically rely on unskilled help with their activities of daily living, such as bathing and dressing.
Some 46 percent of Medicare beneficiaries have three or more chronic conditions, according to the Kaiser Family Foundation. About 8 percent use home health services - a figure that certainly will rise as a result of the settlement.
The financial impact on Medicare isn't clear. Medicare's direct costs for providing the additional coverage will rise, but the higher costs could be offset if the new preventive services reduce the need for acute care, hospitalization or nursing home care.
"With access to some basic therapies, many of these patients may well be able to avoid nursing and hospital care," said Judith Stein, director of the Center for Medicare Advocacy (CMA) and a lawyer who represented plaintiffs in the class action. "The settlement is a victory for people who need care, and it will save money for states and the federal government who otherwise would be paying for services that shouldn't be necessary."
Jimmo's care, for example, has been covered by Vermont's Medicaid program, but some patients have had to dip into their own pockets to cover some of these services.
Court approval of the final settlement isn't expected for several months. After that, Medicare will have a year to implement the changes and educate healthcare providers about them.
But under the terms of the settlement, more than 10,000 Medicare beneficiaries who were denied benefits for skilled services before January 18, 2011 (when the lawsuit was filed) will have their claims re-examined.
CMA urges patients who think they qualify for coverage under the settlement's terms to start pushing for it right away by submitting their claims to Medicare. "This is the policy that the government says is now in effect, so patients should push that immediately," says Gil Deford, CMA's lead counsel on the case.
ADVOCATING FOR BENEFITS
If you think your care should be covered under the terms of the settlement, here are some key steps to take while you wait for the new rules:
* Educate healthcare providers. Patients shouldn't assume that skilled nursing facilities or home healthcare providers will immediately understand the settlement's impact. "Ask them how they plan to implement it, and make the question specific to your own needs," said Joe Baker, president of the Medicare Rights Center, a non-profit organization that provides free Medicare counseling services.
* Be persistent. "It will take a while for this to be operationalized," says Baker, who recommends that patients appeal any denials of claims.
* Get help. 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: https://shipnpr.shiptalk.org/shipprofile.aspx.
The Medicare Rights Center also offers free counseling by phone; (1-800-333-4114).
For Jimmo and other Medicare beneficiaries affected by the settlement, the direct impact will be better care, according to Michael Benvenuto, project director of the Medicare Advocacy Project at Vermont Legal Aid, who served as co-counsel in the lawsuit.
"When healthcare providers don't think Medicare will pay their bills, they're less likely to provide the full care that patients need," he says. "For Glenda, this settlement will insure that she gets adequate maintenance care in her home for as long as she can stay there."
(The writer is a Reuters columnist. The opinions expressed are his own. For more from Mark Miller, see link.reuters.com/qyk97s)
(Follow us @ReutersMoney or at http://www.reuters.com/finance/personal-finance. Editing by Linda Stern and Steve Orlofsky)