HEARING - U.S. Senate Special Committee on Aging

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aide services, however, usually exceeds $10 per hour. Even if an
individual needed aide services only four hours per day, seven
days a week, he would have to pay $1,200 per month or $14,400 per
year. This is a crushing burden for many people on limited
incomes.
Because of their inability to afford these charges,
many patients either continue at home with dangerously inadequate
care, or are forced to enter nursing homes. Thus instead of
helping beneficiaries with the relatively modest cost of home
health care, our financing system will often force patients into
institutions where the huge monthly rates will soon be borne by
the Medicaid program.
IV. TNP&ATENT HOSPITAt REHABTLITATTON
For many years, Medicare patients in need of the kind of
multidisciplinary, coordinated rehabilitation available only to
hospital inpatients, have also been faced with restrictive
Medicare coverage policies. Too often these restrictive policies
result in patients being unable to gain access to this important,
restorative care or to patients being prematurely discharged.
Typically, the patient in need of hospital rehabilitation has
suffered a stroke, traumatic brain injury, paralysis, and/or
amputation. With an intense program of multidisciplinary therapy
(often including physical therapy, occupational therapy, speech
therapy, and rehabilitative nursing) provided by a team of
professionals and coordinated by a physician trained in
rehabilitation, these patients can often regain sufficient
independent function to return home.
Unfortunately, the Health Care Financing Administration often
denies coverage for this care on the basis of arbitrary rules and
erroneous conclusions. Patients are denied coverage because they
do not need three hours per day of physical and occupational
therapy (the '3-Hour Rule'), although they may need speech
therapy and other rehabilitative care. Patients are denied
because their amputations are 'only' bo2w the knee, or because
they 'only' have upper extremity paralysis. Many are denied
coverage on the unsubstantiated premise that they could receive
the intense, coordinated, multidisciplinary rehabilitation they
need at a skilled nursing facility or as an outpatient. The
Center is responding to this dilemma for elderly and disabled
patients in a variety of ways:
1. A new partnership has been formed between Gaylord
Hospital in wallingford, Connecticut, a free standing
rehabilitation hospital, and the Center for Medicare
Advocacy. Center staff are working in conjunction with
Gaylord Hospital to appeal unfair Medicare denials for
Gaylord's patients.
2. Individual appeals are being taken for patients
referred to the Center. Appeals are presently in
progress for patients denied Medicare who do not meet
the '3-Hour Rule' and who are below-the-knee amputees,
but whose physicians have certified that inpatient
hospital rehabilitation is medically necessary.
3. Center attorneys are continuing to litigate the class
action lawsuit, Ronoer v Bowen, H-80-99 (MJB) D. Conn
5/1/85. Hooperw has been certified as a class action
comprised of all Medicare patients in New England who
have been denied Medicare coverage for inpatient
hospital rehabilitation despite physician certification
that such care is reasonable and necessary. The United
States District Court for the District of Connecticut
has issued a series of decisions, the latest on may 1,
1985,. finding that the criteria used by HCFA to deny
Medicare coverage are void and of no effect for failure
to publish in the Federal Register because they include
more restrictive and burdensome criteria than exist In