This week, a federal court will sign a settlement agreement between the federal government and a class of litigants affecting the administration of the Medicare program. Because the settlement agreement comes in the context of a class action federal lawsuit, it will affect all Medicare beneficiaries across the country.
Medicare is a health insurance program that the federal government created and administers. Medicare is available to aged individuals, defined as those individuals age sixty-five or older, and individuals who are totally and permanently disabled for a period of, at least, two years. Working individuals pay into the Medicare program in order to receive the benefits when they are aged or disabled.
Medicare pays for hospital stays, physician services, prescription drugs, and rehabilitative services. The settlement agreement affects one aspect of rehabilitative services for which the Medicare program pays.
Assume the following facts: Mr. Smith breaks his hip. Mr. Smith is taken to the hospital and has surgery performed upon his broken hip. Mr. Smith spends four days in the hospital. After his hospital stay, Mr. Smith is discharged to a nursing facility (that is, a nursing home) for rehabilitation of his newly-mended broken hip.
The Medicare program will pay for up to 100 days of rehabilitative services in the nursing home. Medicare pays days one through twenty in full. For days twenty-one through 100, there is a $144.50 per day co-payment, which many policies of private insurance pick up.
Until this settlement is in place, Medicare and the nursing home will tell family members that only if Mr. Smith is improving can he continue to receive Medicare payment for his rehabilitative services. If the services are necessary to maintain Mr. Smith’s current health status, both Medicare and the nursing home will tell Mr. Smith and his family that Medicare will no longer pay for his rehabilitative services.
Where Mr. Smith falls upon the improvement versus maintenance continuum is, therefore, very important, and oftentimes difficult to judge. Many older people would benefit from rehabilitative services in order to maintain their current health status. If they stop receiving rehabilitation, they will fail to maintain their current health status, and they will be susceptible to more health issues.
If Mr. Smith is discharged too soon, he may go home and fall again, breaking the same hip or another part of his body. Permitting him to recuperate in the nursing facility for a longer period of time may, in the long run, save Mr. Smith (and the Medicare program), because he will go home stronger and more capable of caring for himself.
Furthermore, there are individuals who suffer from chronic conditions, such as Parkinson’s disease or multiple sclerosis, for whom this settlement will bring tremendous benefit. Individuals with chronic conditions such as these are not expected to get better. There simply is no cure for many chronic conditions. But these individuals could greatly benefit from receiving rehabilitative services that would permit them to maintain their current levels of functioning for longer periods of time.
For individuals who suffer from chronic conditions, this settlement will mean quite a bit.
In speaking with a friend of mine who is a physical therapist, there is no doubt that this change in the administration of the Medicare program will tax the capacity of physical therapists. If Medicare begins to freely pay for rehabilitative services designed to maintain, as opposed to improve, elderly individuals and individuals with chronic conditions, there will be many more people receiving rehabilitative services. In the long run, though, providing these services will lessen the acute care needs of these individuals and reduce the overall cost of health care in this country.
Many families assume Medicare coverage ends the moment improvement stops, but that is not always the case. Understanding what Medicare may cover—and why—can help families advocate more effectively when care decisions and benefits are on the line.