Proposed Settlement Could Expand Medicare Coverage

 A proposed class-action settlement may help tens of thousands of people with chronic conditions and disabilities qualify for Medicare coverage.

 Presently, Medicare guidelines indicate that coverage should be denied if a patient reaches a plateau and is not improving.  As a result, if a patient suffering from a chronic condition could not demonstrate a likelihood of medical or functional improvement, Medicare would not pay for home health care, skilled nursing home stays, or outpatient therapy.  Since many families could not afford these services out-of-pocket, many patients ultimately did not receive the recommended treatment.

 Under the proposed settlement, Medicare will pay for those services needed to “maintain the patient’s current condition or prevent or slow further deterioration,” regardless of whether the patient’s condition is likely to improve.  The focus would be on the patient’s need for skilled care, rather than his or her potential for improvement. 

 The proposed settlement was submitted on October 16, 2012 to the Federal District Court in Vermont.  If approved, it is expected that the court will takes several months to finalize the settlement, and that Medicare will take an additional year to formally implement the policy change.