Show #539 Airing Sunday, 9/5/10
Let’s take a common situation. Your mom needs help with walking, bathing, or other common needs. She’s been getting assistance from Medicare. But now you’re being told that the Medicare will be ending because your mom is “stable” and “will not improve.” What are your rights in a situation like this? Here to explain is my law partner, Mike Solomon.
Question: What's the most common reason people are thrown off Medicare?
Answer: The most common reason is that the care being provided will not help a person improve their condition. For example, let’s say a person suffers a stroke or a prolonged illness and needs therapy to walk again. Medicare will cover the therapy at home or in a nursing home. But after a week or two, Medicare determines that the person is not making further progress. Medicare then cuts off payments, which ends the care.
Question: Is Medicare acting legally?
Answer: No. In many cases, the person needs the care to maintain their current condition.
Under the Medicare law, that should be enough to continue to receive Medicare coverage. Let me give you 2 specific sections of the law that viewers should have ready in case they are wrongfully denied:
1.)
42 CFR 409.32©): “Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.”
2.) 42 CFR 409.44 (c)(2)(iii): the regulations support coverage if “the skills of a therapist are necessary to perform a safe and effective maintenance program.”
Question: If the law clearly says that Medicare should be available for maintaining a person's condition, why doesn't Medicare follow that?
Answer: I can’t explain how this came about, but Medicare requires improvement and denies coverage if no improvement is likely. This is done often, and all over the country. It has become deeply ingrained in the system.
Question: Is Medicare's position harmful?
Answer: Yes. It keeps people with debilitating, long term and chronic conditions from receiving the care they need. It tends to harm people most who suffer from multiple sclerosis, Alzheimer’s, ALS, spinal cord injuries, diabetes, Parkinson’s, hypertension, arthritis, and stroke.
Question: Where can I get help?
Answer: Contact the center for Medicare advocacy: improvement@medicareadvocacy.org or 860-456-7790.
Don’t let Medicare cut off your benefits improperly. Make sure you know your rights. Any questions, give Mike a call.
