Home Health & Hospice Week

Court says chronic care should not be barred from the benefit, as long as there's a skilled need.

A decision by a Vermont federal court could result in more Medicare patients on your rolls -- eventually.

Vermont Medicare beneficiary Sandra An-derson sued the Department of Health and Hu-man Services over its so-called "stability presumption," which says "coverage is automatically denied for patients whose conditions are stable during the covered period," notes the ruling filed Oct. 25 in Anderson v. Sebelius.

Background: Anderson received care for six episodes following a second stroke and hospital stay, the ruling notes. For all but the initial post-hospital episode, Medicare denied therapy and other skilled services for not being reasonable and necessary. The Administrative Law Judge and Medicare Appeals Council upheld the decision.

Holding the bag: However, Anderson was not on the hook for the episodes. Instead, her home health agency, the Visiting Nurse Association of Chittenden and Grand Isle Counties, was held financially responsible because "the VNA did not sufficiently notify Anderson that Medicare would not cover her services," the opinion says.

Anderson filed suit anyway, and Judge Christina Reiss has ruled that the case must go back to the ALJ, which must consider Anderson's coverage without the stability presumption. "A patient's chronic or stable condition does not provide a basis for automatically denying coverage for skilled services," Reiss concludes. In other words, it is "incorrect" to conclude that "skilled services are not covered 'when a patient's condition is stable and unlikely to change,'" the opinion says.

"People with chronic conditions are being denied care in the mistaken belief that Medicare requires improvement of a person's condition as a prerequisite for coverage," Rep. Joe Courtney (D-Conn.) told The New York Times about the decision and a similar one for nursing homes. "That's not in the law. It's urban legend."

Jacob S. Speidel, a lawyer at Vermont Legal Aid who helped represent Anderson, told the Times: "Medicare often denies coverage for home health services because people have stable chronic conditions. We believe this practice does not comply with Medicare law and regulations."