Access to Health Care
Access to health services and treatments is an important part of a patient's care. For those living with Parkinson's disease today, these factors directly impact symptom management and quality of life. The ability to see a specialist and to pay for medications and care impacts the course of an individual's disease. The Michael J. Fox Foundation (MJFF) supports policies that increase patients' access to health care services and improve well-being.
Telemedicine is the remote delivery of health care services and clinical information using telecommunications technology, including internet, cellular, wireless, satellite and telephone services.
Access to movement disorder specialists -- doctors who have additional training in Parkinson's disease -- is limited in certain areas of the country. Being able to see a physician using a computer, at home or in a local doctor's office, could improve care for those who cannot travel to a specialist. Studies have shown that telemedicine can reduce hospitalization and keep people living safely and independently for longer.
A bill to expand telemedicine services for individuals covered by Medicare was introduced in 2015 but did not make it out of committee. MJFF will continue to support legislation that increases the remote delivery of health care services for those with limited mobility.
Individuals living with Parkinson's disease may be eligible for certain government benefits such as Social Security, Medicare/Medicaid or disability services. MJFF will work with legislators to enact policy and establish programs that provide sufficient care and coverage for people with Parkinson's. The Foundation encourages patients and families to become familiar with these programs and know their rights.
Medicare Therapy Caps
The Balanced Budget Act of 1997 created limits, or caps, on the amount of outpatient physical, occupational and speech-language therapy a Medicare beneficiary can receive each calendar year. There is currently a combined $1,940 yearly cap for physical therapy and speech-language therapy, and a separate $1,940 yearly cap for occupational therapy. Once those amounts are reached, beneficiaries who require additional services in the calendar year are responsible for 100 percent of the cost. In addition to the caps, a manual medical review is required once a beneficiary hits $3,700 in therapy services.
To mitigate the impact of these caps, Congress created an exceptions process for services deemed medically necessary. However, the exceptions process is temporary and must be reauthorized by Congress every year. It is set to expire on December 31, 2017.
The Parkinson's community has long advocated for a complete repeal of these caps to ensure people with Parkinson's have access to medically necessary therapy services. The Foundation will continue to educate lawmakers on the need to eliminate the caps and will push for policies that repeal them altogether.
If care continues to be medically necessary beyond the $1,940 cap, ask your therapist to:
- Apply a KX modifier to the therapy code to show the use of the therapy cap exceptions process.
- Submit documentation that supports the medical necessity of continuing therapy. The documentation should indicate why the patient requires continued skilled therapy as the absence of this information may result in Medicare's decision to deny claims for these services.
Medicare Improvement Standard
Up until 2013, the "improvement standard" was an inaccurate policy being arbitrarily applied by Medicare providers, contractors and adjudicators that required beneficiaries to show improvement to continue receiving physical, occupational and speech-language therapy. For people with chronic degenerative conditions like Parkinson's, therapy is not intended to result in improvement; it's used to help maintain function and increase quality of life. Therefore, people with PD could be denied therapy services under this inaccurate "improvement standard."
The "improvement standard" was challenged by several patients and advocacy groups, including the former Parkinson's Action Network, in the case of Jimmo v. Sebelius. The parties reached a settlement in January 2013 declaring Medicare beneficiaries cannot be denied coverage for physical, occupational and speech-language therapy, as well as other select services (including skilled nursing facilities, inpatient rehabilitation facilities and home health), solely for lack of improvement. The Centers for Medicare and Medicaid Services (CMS), which administers the Medicare program, was given one year to update its policy manual and execute a nationwide education campaign for all who make Medicare determinations. Unfortunately, while the policy manual has been updated, confusion remains and people are still being denied coverage. In Spring 2016, the parties returned to court to pursue further legal action to ensure the Jimmo settlement is fully and accurately implemented.
In February 2017, the court ordered CMS to execute a "corrective action plan" to ensure beneficiaries are no longer being denied coverage due to the "improvement standard." The plan includes:
- A new CMS webpage dedicated to Jimmo
- A published corrective statement disavowing the "improvement standard"
- A posting of frequently asked questions
- New training for contractors making coverage decisions
The corrective action plan must be complete and implemented by September 4, 2017.