Lawsuit Alleges CMS Illegally Denies Care to Chronically Ill, Disabled
On Tuesday, the Center for Medicare Advocacy filed a lawsuit in U.S. District Court in Vermont on behalf of five national organizations alleging that Medicare is illegally denying thousands of chronically ill U.S. residents needed therapies and medical services, Chicago Tribune reports.
The suit seeks to challenge a policy that requires patients to achieve "demonstrable improvements in functioning" before Medicare will pay for physical, speech or occupational therapy, as well as skilled nursing care. Medicare will not cover services if such improvements are absent, according to the Tribune.
According to the legal complaint, Medicare is obligated by law to cover care and therapies that are "reasonable and necessary for the diagnosis or treatment of illness or injury." However, critics say that program administrators have decided that services will be covered only if patients show signs of getting better, the complaint notes (Graham, Chicago Tribune,Â 1/18).
The lawsuit was filed by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of four individuals from Vermont, Connecticut, Rhode Island and Maine, and five organizations:
- the National Multiple Sclerosis Society;
- the Parkinson's Action Network;
- the Paralyzed Veterans of America;
- the National Committee to Preserve Social Security and Medicare; and
- the American Academy of Physical Medicine and Rehabilitation.
Lawsuit Not First Criticism of Policy
Last May, Rep. Joe Courtney (D-Conn.) wrote a letter to CMS, which was signed by 16 other lawmakers, arguing that the improvement standard is illegal and urging the agency to clarify its reimbursement policies. "Medicare coverage determinations should not be based on whether the patient's underlying condition is likely to improve," he wrote, adding, "In fact, federal regulation actually states the opposite" (Pecquet, "Healthwatch," The Hill,Â 1/18).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.