Can individuals diagnosed with Multiple Sclerosis qualify for Medicare?

Individuals with Multiple Sclerosis qualify for Medicare in the same ways as any other individual. First, someone with MS can qualify for Medicare simply by turning 65 as an American citizen and receiving Social Security benefits.

Younger persons with Multiple Sclerosis qualify for Medicare coverage before age 65 if:

(1) Social Security determines that they are permanently disabled; and
(2) they have received Social Security disability benefits for 24 months.

Simply having a long-term illness or needing long term care does not preclude you from Medicare coverage. However, beneficiaries are sometimes denied Medicare coverage for services based on a chronic or stable condition, the determination that their condition will not improve, or that the services will simply maintain, rather than improve, their condition. However, people should not be denied benefits based only on a diagnosed long-term illness such as MS.

What is MS?

Multiple sclerosis (MS) is a degenerative disease of the central nervous system. It disrupts the flow of information both within the brain and between the brain and body. The cause of MS remains unknown, but scientists suspect that a combination of environmental and genetic factors may contribute to the risk of developing MS. The disease is unpredictable and the exact symptoms, severity, and progress of MS vary between individuals.

Services for Multiple Sclerosis

Medicare coverage determinations should be based on medical necessity and specific qualifying criteria for each health care setting and service. Certain services are excluded from coverage under the Medicare Act, while others are limited depending on the qualifying criteria in each case.

Medicare beneficiaries have legal entitlement to an individualized assessment to determine if they are qualified for coverage. Such assessments must be based on valid standards for each service.

People with MS may be eligible for occupational, physical, and speech therapy provided that the services are medically necessary, skilled, and do not violate Medicare’s expense caps.

These services are available even if there is no prospect of restoring prior function, and the only benefit is to maintain the covered individual’s condition. As of early 2018, the firm caps previously in place on annual occupational, physical and speech therapy have been eliminated and replaced with thresholds that Medicare administrators use to monitor spending and suspicious claims.  

Unfortunately, sometimes individuals diagnosed with MS are denied physical therapy benefits on the ground that they will not improve. This is improper. Medicare coverage may be warranted where skilled therapy is required to maintain the individual’s current condition or slow further deterioration.

Medicare also offers a limited amount of nursing home care, but only in limited circumstances. However, individuals diagnosed with MS may avail themselves of Medicare’s home health benefit and hospice benefit for long term care and coverage.

Home health care benefits & MS

Unlike the Medicare skilled nursing facility benefit, which provides coverage for a short period of time, Medicare coverage can be available for long-term home health care if qualifying criteria are met. There is no legal limit on the duration of time for which home health coverage is available.

Further, Medicare covers home health services in full, with no required deductible or co-payments from the beneficiary. Services must be medically necessary, reasonable, and the following criteria must be met:

  • a plan of care that is or will be signed by a physician,
  • the patient is currently homebound or will become homebound (a person is considered “homebound” if leaving the home requires considerable and taxing effort, including personal assistance, the use of a wheelchair, or crutches);
  • the patient requires, or will require, physical therapy, speech therapy, or intermittent skilled nursing care; and
  • the home care is provided by a Medicare-certified provider, or under an arrangement with such a provider.

Medicare home health coverage should not be denied due to an MS diagnosis or a determination that a patient suffers from a condition that is chronic or unlikely to improve. Each patient should receive an individualized assessment of their right to coverage.

What if I am denied Medicare coverage?

Medicare coverage is all too often denied to individuals who are legally qualified for coverage. Such denials are often the result certain chronic conditions, including MS. The pertinent question is whether the patient requires daily skilled nursing or therapy on a daily basis, not what the individual’s heath condition is.

An individual’s potential to be restored to a prior condition, or even just greater than current function, is not the deciding factor in determining whether skilled services are required. Medicare coverage should not be denied simply because the services can only help the individual maintain their condition or slow further deterioration.

However, sometimes Medicare coverage is denied even where it is warranted. This can be the result of errors or the program’s policy goal of cost containment. There even exists some residual belief among health care providers that services are not reimbursed if the patient is not improving, a standard which has been rejected by the Courts.

If you’ve been denied coverage, Medicare has an appeals system to reverse improper denials. If your attending physician believes that a particular care is medically necessary & can be covered by Medicare, you can & should appeal.

Further, if you’re a nursing home resident and your facility has issued you a notice that Medicare coverage is not available, you have a right to request the nursing home to submit a claim for a formal Medicare coverage determination.

The facility is required to submit a claim if the resident or their representative requests one. Once a claim is submitted, the patient is not required to pay until a Medicare delivers a formal determination.

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