By Susan Jaffe MARCH 14,
2018
{UPDATED
at 10 a.m. ET on March 14]
Physical
therapy helps Leon Beers, 73, get out of bed in the morning and maneuver around
his home using his walker. Other treatment strengthens his throat muscles so
that he can communicate and swallow food, said his sister Karen Morse. But in
mid-January, his home health care agency told Morse it could no longer provide
these services because he had used all his therapy benefits allowed under
Medicare for the year.
Beers,
a retired railroad engineer who lives outside Sacramento, Calif., has a form of
Parkinson’s disease. The treatments slow its destructive progress and “he will
need it for the rest of his life,” Morse said.
But
under a recent change in federal law, people who qualify for Medicare’s therapy
services will no longer lose them because they used too much.
“It is
a great idea,” said Beers. “It will help me get back to walking.”
The
federal budget agreement Congress approved last month removes annual caps on
how much Medicare pays for physical, occupational or speech therapy and
streamlines the medical review process. It applies to people in traditional
Medicare as well as those with private Medicare Advantage policies.
As of
Jan. 1, Medicare beneficiaries are eligible for therapy indefinitely as long as
their doctor — or in some states, physician assistant, clinical nurse
specialist or nurse practitioner — confirms their need for therapy and they
continue to meet other requirements. The
Centers for Medicare & Medicaid Services (CMS) last month notified health
care providers about the change.
And
under a 2013 court settlement, they
won’t lose coverage simply because they have a chronic disease that doesn’t get
better.
“Put
those two things together and it means that if the care is ordered by a doctor
and it is medically necessary to have a skilled person provide the services to
maintain the patient’s condition, prevent or slow decline, there is not an
arbitrary limit on how long or how much Medicare will pay for that,” said
Judith Stein, executive director of the Center for Medicare Advocacy.
But
don’t be surprised if the Medicare website doesn’t mention the change.
Information on the website will be revised “as soon as possible,” said a
spokesman, who declined to be identified. However, information from the
800-Medicare helpline has been updated.
Until
then, patients can refer to the CMS update posted
last month for providers.
Lifting
the therapy caps is just one of the important changes Congress made for the 59
million people enrolled in Medicare. Here are two others:
Shrinking
The ‘Doughnut Hole’
Beneficiaries
have long complained about a coverage gap, the so-called doughnut hole, in
Medicare drug plans. That’s when the initial coverage phase ends — this
year, that happens after the beneficiaries and their insurers have paid $3,750
for covered drugs. When it happens, a patient’s share of prescription costs
shoots up. This year, when people hit this stage, they are responsible for
paying up to 35 percent of brand-name drug costs.
When
beneficiaries’ total yearly drug expenses reach a certain amount ($5,000 this
year), they enter the catastrophic coverage stage and pay just 5 percent of the
costs. But studies have shown that fewer than 10 percent of beneficiaries spend
enough to reach that last stage.
The
Affordable Care Act had called for the patient’s doughnut hole share to be
narrowed to 25 percent by 2020, but the budget deal moved up that
adjustment to 2019.
Much of
the drug cost will be shouldered by pharmaceutical companies. And those
payments by drugmakers will also count as money paid by patients, which will
help them progress to the catastrophic level more quickly, said Caroline
Pearson, senior vice president at Avalere Health, a
research firm.
The deal
could have an added attraction. “Premiums will come down because the drug plans
are not being required to cover as much as they used to,” Pearson added.
Lower
premiums will also save money for the government because it will spend less on
subsidies for low-income beneficiaries.
Expanding
Medicare Advantage Benefits
Another
important change allows private Medicare Advantage plans in 2020 to offer
special benefits to members who have a chronic illness and meet other criteria.
Currently,
these private insurance plans, which limit members to a network of providers,
treat all members the same.
But
under the budget law, benefits targeting those with chronic diseases do not
have to be primarily health-related and need have only a “reasonable
expectation” of improving health. Some examples that CMS has suggested include
devices and services that assist people with disabilities, minimize the impact
of health problems or avoid emergency room visits.
This
wider range of benefits might help people remain at home, increase their
quality of life and reduce unnecessary medical expenses. “We’re really excited
that the law is catching up with what plans have known for a long time,” said
Mark Hamelburg, senior vice president of federal programs at America’s Health
Insurance Plans, an industry association.
But the
changes will affect only those beneficiaries enrolled in these private plans,
about a third of the Medicare population. “We would like to see some of these
innovations happen in the traditional Medicare program as well, so that all
beneficiaries would be able to reap these benefits,” said Lindsey Copeland,
federal policy director at the Medicare Rights Center.
KHN’s coverage of these topics is supported by John A. Hartford Foundation andThe SCAN Foundation
[Correction: This story was updated on March 14 to make clear
that the Centers for Medicare & Medicaid Services (CMS) last month
notified health care providers about a change that gets rid of coverage caps on
therapy services. CMS was not writing to providers about a 2013 court
settlement on improvement standards.]
Susan Jaffe: Jaffe.KHN@gmail.com,
@SusanJaffe
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