Obama administration to settle lawsuit over Medicare rules


WASHINGTON — The Obama administration has agreed to settle a class-action suit by revising rules that have barred tens of thousands of Medicare beneficiaries from getting coverage for skilled nursing-home care, home health care and various forms of outpatient therapy.

For decades, the federal health program for the elderly and disabled has denied claims when such care was not expected to result in an improvement of a patient’s condition.

Under the proposed settlement — submitted to and awaiting approval by Christina Reiss, the chief judge of the U.S. District Court in Vermont — the administration will revise that policy so that the care is covered if it maintains a patient’s condition or slows the pace of deterioration. Improvement will not be required.

Judith Stein, director of the nonprofit Center for Medicare Advocacy and a lead counsel for the plaintiffs — five individuals and six national organizations — said the current policy of requiring improvement from care has had a devastating impact on people with a wide range of conditions. Elderly people with Alzheimer’s or Parkinson’s diseases, middle-aged people with multiple sclerosis, and veterans with brain injuries or paralysis often are unable to pay the bills for home or outpatient care on their own, she said.

“Very, very often people go without any care or without enough care, and very often that leads to people getting worse,” she said. The news of the settlement was reported by the New York Times.

The original policy is not enshrined in law or regulation. But it is spelled out in the manual relied on by providers filing claims and by the Medicare representatives responsible for deciding what claims are covered. The manual now will be changed.

The named plaintiffs in the case and any Medicare beneficiary who was denied coverage since the suit was filed on Jan. 18, 2011, will also have a chance to reapply for coverage.


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