Commonly known as MS, multiple sclerosis is a disease in which the patient’s immune system attacks his or her central nervous system (CNS). Specifically, MS targets myelin, a substance that forms a protective coating around the nerve fibers of the CNS. Currently, there is no cure for this progressive disease. This leads to questions about Medicare coverage for certain services. In this post, we discuss multiple sclerosis and Medicare, focusing on the case Jimmo v. Sebelius and how it benefits MS patients.
Do You Qualify for Medicare if You Have Multiple Sclerosis?
There are five ways to qualify for Medicare:
- Are age 65 or older, reside in the United States, and are either a U.S. citizen or permanent U.S. resident who has lived here continuously for at least five years
- Receive Social Security Disability Insurance (SSDI) for 24 months or more, even if you aren’t yet 65
- If you were approved for SSDI due to amyotrophic lateral sclerosis (ALS, better known as Lou Gehrig’s disease), you qualify for Medicare the same month your SSDI benefits begin
- Receive Railroad Retirement Benefits
- Have a diagnosis of End-Stage Renal Disease (ESRD)
As long as you meet at least one of these criteria, you qualify for Medicare. You cannot be denied coverage due to multiple sclerosis or any other medical condition.
What Is the Medicare Improvement Standard?
Medicare services have certain guidelines or restrictions attached to them. The most common is having to use a healthcare provider who accepts Medicare. Another coverage restriction is informally known as the Medicare improvement standard.
In essence, the improvement standard states that the service is only covered if its purpose is returning the patient to a state of health. For example, if you break your leg, Medicare covers physical therapy provided your doctor deems it necessary and signs off on a plan of care. In addition, your doctor expects you to regain normal use of your leg within a “reasonable” period of time. This last part exemplifies the improvement standard.
It’s important to note that this requirement barred thousands of patients with chronic illnesses from receiving Medicare coverage for necessary care that helped stabilize their condition. That’s because, according to the standard, the patients were not “improving” and Medicare did not cover rehabilitative services categorized as “maintenance.”
What Is Jimmo v. Sebelius?
Jimmo v. Sebelius is a lawsuit brought against then-Secretary of Health and Human Services, Kathleen Sebelius. In it, the plaintiff – six individuals (one named Glenda Jimmo) and seven organizations – alleged that the improvement standard was illegal.
Plaintiffs argued that the Medicare statute and regulations made clear the illegality of the improvement standard. The filing named a variety of regulations that specify “restoration potential” not being a deciding factor when determining whether certain services are required.
The court agreed and on January 24, 2013 approved the settlement agreement of Jimmo v. Sebelius. Medicare could not deny coverage for skilled maintenance services to beneficiaries with chronic conditions that are not expected to improve. In addition, the Centers for Medicare and Medicaid Services (CMS) was to revise policy manuals, guidelines, and instructions. In addition, CMS had to develop and implement a campaign to educate providers about this policy change.
However, plaintiffs returned to court in 2016, arguing that CMS has failed to fulfill its obligation according to the settlement agreement. Specifically, CMS failed to implement the educational campaign many saw as the cornerstone of the agreement.
Keep reading to learn more about the skilled services Medicare covers for MS patients and others with chronic, progressive conditions.
When Does Medicare Cover Home Healthcare?
Medicare covers long-term home healthcare for beneficiaries who meet the following criteria:
- Their physician signs off on a plan of care
- The patient is homebound, meaning considerable effort is required to leave home (the patient is permitted to leave home occasionally, such as to attend religious services or take short walks)
- Physical, speech therapy, or intermittent skilled nursing care is either needed or will be needed
- A Medicare-approved provider administers the home healthcare
To be considered eligible, services must require the skills of a healthcare professional.
When Does Medicare Cover Skilled Nursing Facility Care?
Medicare covers care from a skilled nursing facility (SNF) if the patient meets the following requirements:
- A doctor certifies such care is necessary
- Admittance in an SNF occurs within 30 days of a qualifying 3-day hospital stay (please see our article on hospital observation for more information)
- The patient requires daily skilled nursing or rehabilitation that can only be provided on an in-patient basis
- The SNF is approved by Medicare
Covered SNF services include nursing care, therapy (physical, occupational, and/or speech), a semi-private room, medications, meals, social services, and medical equipment and supplies.
Advocating for Coverage if You Have MS
Despite the court’s findings in Jimmo v. Sebelius, Medicare often denies coverage for these services to MS patients and others with chronic conditions. The pertinent question is whether the patient needs skilled nursing or home healthcare, not whether he or she will recover. Please see the following graphic for more advocacy advice.
Do You Have Questions about Multiple Sclerosis and Medicare?
If you have questions specific to multiple sclerosis and Medicare coverage, call the National MS society at 800-FIGHT-MS (800-344-4867). They have partnered with the Center for Medicare Advocacy to assist Medicare beneficiaries who have multiple sclerosis.
Do you have questions about your Medicare coverage? The licensed agents at Medicare Solutions are here to help. Just call us toll-free at 855-350-8101 to get started.
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