How Changing Outpatient Therapy Caps Will Affect New York Medicare Beneficiaries

by David Goldfarb

Recent changes to the law have extended outpatient therapy and home health care coverage for Medicare recipients. Unfortunately, some Medicare beneficiaries still find that their claims get denied under improper or outdated standards of review. An experienced attorney can help recipients determine what services they are eligible for, and advise them how to appeal improper denials.

Medicare Recipients Should Know About Two Important Changes

While Medicare coverage rules have recently changed in many ways, two in particular have the potential to greatly affect New York Medicare subscribers. The first is a class action settlement initiated by Medicare recipients in Vermont. Medicare Advocacy reports that Medicare denied the claims these subscribers filed to pay for home health services on the basis that they could not show improvement to their medical conditions as a result of the services. This is not the proper standard under which to review such services. Rather, home health services must meet six other threshold requirements for Medicare coverage (none of which require improvement).

In 2013 the Centers for Medicaid and Medicare Services agreed to a settlement by which it would revise the Medicare Benefit Policy Manual. The manual now eliminates any suggestion that the beneficiary must demonstrate improvement to qualify for home care services. Medicare, however, continues to deny claims for eligible home healthcare services on the basis of the erroneous “improvement” standard. This is why Medicare subscribers must understand their eligibility for home care services and fight improper claim denials.

This settlement was supported by further Medicare coverage protected under the Bipartisan Budget Act of 2018. According to Medicare Advocacy, this law contained a “health extenders” package that changed many Medicare coverages.

One important change repealed the annual payment limits on outpatient physical, speech, and occupational therapy services for Medicare recipients. Before this change, Medicare subscribers had an annual limit (or “cap”) on the amount of benefits available for these services. Medicare required therapists to seek exceptions to provide services beyond these annual limits. Therapists did not, of course, always provide these exceptions, leaving many subscribers without necessary outpatient therapies as a result.

The repeal of annual payment caps may expand services to eligible Medicare recipients who badly need them. Again, subscribers must know about this coverage, and vigorously appeal any claim that Medicare denies under an old standard of annual payment caps.

Protect Your Right to Medicare Benefits With the Assistance of a New York Elder Law Attorney

Senior citizens have the right to access all Medicare coverages for which they are eligible. The elder law attorneys at Goldfarb Abrandt Salzman & Kutzin have decades of experience in helping seniors assert their rights to Medicare coverage. By understanding all coverages to which they are entitled, senior citizens can access their necessary medical care, and ensure that Medicare does not improperly deny their claims. Call (212) 387-8400 today to schedule a consultation with an experienced New York elder law attorney.