Medicare beneficiaries are still wrongly denied coverage of skilled nursing, home healthcare or outpatient therapy because of their failure to improve, reports The New York Times.
The following are among the rationales cited in the article for why these beneficiaries are denied coverage: They're not improving. They've "reached a plateau." They’re "stable and chronic," or have achieved "maximum functional capacity."
But the assertion that Medicare coverage can be denied for failure to improve is incorrect. According to The New York Times, a federal judge in August ordered CMS to make better its efforts to notify healthcare providers and Medicare adjudicators that the so-called improvement standard was not in effect anymore.
The article cites the 2013 settlement of a class-action lawsuit, which specified that maintenance is what matters when it comes to a decision to deny coverage. The report states Medicare is required to cover skilled care and therapy when they are "necessary to maintain the patient's current condition or prevent or slow further deterioration."
By early next month, CMS must explain how it plans to mount a better educational campaign, according to the report.
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