HEARING - U.S. Senate Special Committee on Aging

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139 492 5-86 New Developments 10,937 health Insurance Atanual 13 (ilI1-13: which is intendl%] to guide intetmcdiaries u (Footnote Continued) by r ans-& ithe sp iion d * qualified phygal tti,,spou thl the .eeerni most ix he tccnni.t8l of snh t kvre lh-lnymst of tomplnity o rtne nnd the aity of th patien I phuatiati or he ,ndlitoat of the lt.ituie aWn muot she drivei be sWth the tncent; that the sevic -uicrl ton bhe atey ad effctiely (3) Gait entnhetm and tlaining: Cait evaliation an, peroratied onty hy * qusliied physito theespst or amden training furihd to rslome fumtnsts ins . patient b. kin natneovisio. Servire wkith do nct require the preform, ability to olk h.. tons mied by rloeiat, m. ivrl r ant or apelrii ofd. phyitol ' heCiSnt are no cunidreed rtasmubit ur new e y physical therapy serc eveln if they ar pectoemend (4) Rae of monia or snpervined tenemsm Range by . orf..n physitl i tlerspist. sen (When the intermedfiay Which determins ac pan of the the nnvicoe acive timen onhed d * operri d K mtate which ert han of imlted s type in that lhe mold brn of. have mue been Wrly ikesn of nd dffectbly miilfty (a eWiden Performed tb * *tenhepsst. omly by noes a quaaified sheie thi pbynkcl therapist wn under degree of mion flilt nd his the saenrvion. degree to te ruittedit it rhonad Prate that Xsb servicet wen peoely sspeied. Hotnrn, this anoumptico Is rebuttabie (3) Maintenance therapy Maniotalne theapy. w sand If to the coare, at proccnnif g caims. the inteediary Lke iperiliied kioledge and jeatmenl d a qtualfied therr findr tat physical therspy services *ar am being tiranhed agpist is rquied to design and esuatiLb na maiones noter pe sape.relni., the intarsmallasy shonld deoy sbe progrmt beaed on an initial rehnsation ad peniaie miw eemenet of the patnent's needs, nd cseistent with the petient's W fc) empaity Three mut WA tniee ... be nn expctaion that the enaditicn W itne ~oltn'tly inn * sbIr (and geneliy pdc able) peeled of time bheod x, the anamient made by the (d) P1to al ame wn,,cem Pinenela Sam kneics iebi do phybician of the pastients eestnWois pi l ater any One few-g the akiU of qualilied tehnical or prefeltiosal sneeded wnolItatio, with the quntifted pyales therapist nr personnel ar s ahilod et-ices -es stoen the cinoe. tLb services moDU be rcsaa to the establisihemnt f s rate ttnitn ecieid in #40932(b) Penleiat ar-serie nod offetie maintenar prognam required is cotrcicso inelute, bat -r not linited to. the (olltwingr with. specific ditesu atute. and (d) The smount. frequenty. and duratnoa of the neevice, (i3) Gnerel nwevinion of enci- whicb bau ben most he -nhe. tuoght to the patient: including the actual carrying out of mainteatne peiraun ie. . the perfnraante of dhe rpei. tine onertine required to maintain tunction, dr son enqui 1. Rsratirnin, Te-ape. T. onUtiltue physial theopy a the sWils d a thespnp nod Wo-Id not contnoitote skilled nervic muut among other thinog. be re bte nnd nos r habilitation aieee (ntm pantnrranh frI of thi ntkhe) toy to the treatment of the indiidna'. illn ((ne t Ifn Similarly. rpltious eoncimn to itopen gait tainttiu individ.al s eapected rstoue n psentist -lid be iraig. gtangthk. or endrannot; pnauive ervise to maintin ang niieunot in rlaion to ihe eent andw d l tioo of physil od moOtiol in Parntvcd ntrositie. thkh are not ne ated to therapy se-ice ms qiceld is arhieve -h potrtil. the a PctiFit for of lunction; and i1iv setkinrg de net phys,;-l therapy a-nMu no he eh, sieknd tenabie and ltantitute killed rebabilitatico -eki nereaary. n additar there mnu . be an eperation that the Ptienlts codition sill imporen 42 in CF.lL g nenraly prefict- J40934 pe-eides int hei: able period of siri. Ifeier if st any point in the trent. (a) To mtet the daily hain retqirment spedfied in aent of a illns, it determined that the tae tirom f409.31(bXI). the foilowingS feoqueny i requird: will nrt rtn eria. the erices ilt no longer bhe enaidend li) Skilled nuning wneie reasonable or nlitted tnd nts rhlubililali.. *nd alt. they. tberele. ihould be vites maut he needed and provided 7 days * neek eschaed eni er er rage undee 142 U.S.C . 1349t )tahttj. 12) An inO cniorpt. if skilled ehbilitnia, sm sr 2. Aainteace Prisim. The reptitie ris required not avaiable 7 days a reek,. tbse serviek- mum be nteded to miibains lantion generally do not involewmplex and nnd prdedW at last 3 days. .n . snhistict-td physical ihelrpy procedue.. .and conne qtuntly the judgmet nd skit 'Saromary d a qu-lilied juagment physitnl - thera- grated in Ia-o of defendant pist arc not required fr an saety the Iemne snd of eletitteos. a ther HIM-l3 ond penloted in vil. Hnes-roe, in remain tiona dpplicabte innnnees bk itocn the Steliard h-ledge and fe egolimes Seue n and judtenlm uf a qasilied-physical therpi nnaJsyJnt.'nt msty be Rtulingat 14. requirtd to establis a minrtenance pngranm For eautmpte HIM 13 f31018 p ed, o n pertinint pan: a PAebinna patint s he an not been d r a etentiv A. Gncel-To phySkaal be c.vred heape pbylreal pwtnrm therapy may rtqnime serthe the ervice of mertice.ot relte directly and physicatl pepirkca11 theapis to an to determin nttine whet type dof oeeines sill rTitten tnartnent cocorih regimen, cta~biutd by thtaphykian ure the MnMs to maintnin the psirnt's prsent INo- afM any seedd onstatulian with the qoaliirvd iysienl tiona ir-s-e. the-ritt and mout he reaobl and ntry to the In sa-h sinatoni the initial esluatin o she patient' treatment of tie individual's illness inojoy. need., the dtitring by the qualiiol phyacol itNherapist of B Reaonabl, and JvNezn To mio-Nence be ec-Oidrlred petrne neuoa- whbkh is apprpiatle to the ciaty ble and -tesnay the olieg mtIisian moot .. be mt: and eranc d the patint sod she i-e mlet ohietices d she phyvskin. the intcalaa of the patien or suprt (a) Thle evime muos be consded undr . At.d stan. petnel. re. aide, ur nursin perctnf ito fIanity dAts of medical mom- prnoct ln he a shrrifi ad edrrett t."t ot rr phiMat thra i s heine tarnished treatmet on retri.- 1, the trtient's c-onitiun. hint;d.t h ,acinent the persema -d suchinrequent Medicare and Medicaid Guide delermining whether individual claims for pay. mene are to be covtered hy Melicare. The appli- _ . N 35,374
140 10,938 New Development. 492 S-86 cable regulations and the relevant portions of IIIM-13 clearly contemplate that each patient will receive an individlualized assessment of his need for daily skilled physical therapy ha.srd on the facts and circumstances of his particular case. For example, the regulations authorize coverage for physical therapy "exercises or activities which, because of the type of exercises employed or the crondition of the patient, must he per. lormed by or under the supervision of a qualified physical therapist or occupational therapist to ensure the safety of the patient and the effectiveness of the treatment." 42 C.F.R. §409.33(cX)2) (emphasis added). The regula. tions similarly provide that maintenance physical therapy will quatliy for Medicare coverage -when the specialized knowledge and judgment of a qualified therapist is required to design and establish a maintenance program based on an initial evaluation and periodic res-sessment of tde patient's needs, and consistent with the pAtients capacity and tolerance." 42 C.F.R. §409.33(cX5) (emphasis added). The regulations likewise allow coverage for "[riange of motion exercises which are part of the active treatment of a specific disease state which has resulted in a lss of, or restriction of, mobility (as evidenced by a therapist's notes showing the degree of motion lest and the degree to be restored)" 42 CF.R. *409.33(cX4) (emphasis added). It is clearly contrary to such regulations for an intermediary to deny benefits on the basis of (Footnote Continued) roevateation, u may be required muld r-retittr phyic ."uld net be cosaiTered ressonabie and neersetry. Reptitkua eacreises ts improve pit or maintlin trenthi and Whenr a ptient bau beets under a restorative Ptrysicat enduranc nd sstituive "aking. s=h as pniAdd in sap- theapy pmngo, the physical therapist atud rostuarty be port tsr feeble or Utable patients., re appr iely p- reevahfatln the croditi and -di-atil' any earrcie vrosided by aeppeetire peramnol. eg.. aides or narsing personnel. arid do not require the atiltl of a quaifired ptysigram in ikh the patient is egaged. Consequetly, When is h trmne that no hirtler restoration is Psesibte. the at1 theraopst. pstai thapit shod hs- already designed thr essint.e tasnen pnm reqeired iusd instructed the Pitient. upprtivr, perseesf tor ramily anember here physical 4. Riange of Miion TeaIs Only the qualified physics therpy hi bt funaishd oan - utpti-nt bats) in the therapist nay perfrm range of motOn teu and, terer-, earytni; orit dt thr f em. Therefor, where a maint such tes mosltd emotiotte phpysie therspy. rnee prbram n na nt bestis he athil after the tior tise 5- Therapik EZerrt. - Therapeuttic esere which physmCal theramn pr ra ha beend esapetr ii wuild not muit be performed by or under the sp-rnision of the te gtdert o asna rd ray th xbe treatet a quatitied physIa terapist due either to the type at he patienta ee abtion std oud itti eashaed torap boyerage eerrise tmplneyd or to the condition at the patent wold wider 142 t&C. I l2957yiaXtll monsritute pbysil therapy. Range of motion esertistr C Aiwdicatli . at skatde The fritim ir- dithUasiai require the skills d .quatifrt physical therapst tonly wn Ia teiur tihe apphiyk i at hie aheve geidetinr tn th they are part o the etire tretment af a specit diase mawn gamato medaitina atnd praredoora. astiaird in thre whikh baa resoitit in a he. or restriction at moility (as treatrrent at paticitt eviidened by physical therpy sers ah the degree a motion inst and te ,tnree o be restore.d) ett serh eor. ties, either brinie rf their natere [mi the condition of the 2. Gait Tranintn Gait restitution a*nd training tarnished patint mai aonty her rnrnrd srty and tketiiy by or a patient whese sinliy tar math baas been impiriedl by searaF uster ;th seprnision of a qautifiedt physirat therapist. ttagei masenr. or siriett hrnaeeatity requires the rthts Cketallv. rangne d mntion eirehs hich are mst retaird no dt a qu lilied tPhys ia therapit. H t rae. il gait rcaluati~ss the reete~ttion at a speific loss at sunction bt rather ate and training canno resastorty bh otXetrd sr impro r related in the nmaintnan of fortiat tr a2) de n.t atgnificantty the patient's ability to -ath. seth ri, requir tb thus1 of a quaifid physical thepist. 1 35,374 informal presumptions, or "rules ol thumb," that are applied across the hoard without regard to the mcdical condition or thcrapeutic requirements of the individual patinit. Cf. City of New York, supra. 742 F.2d at 732 733 (enjoining administrative practice of employing a presumption in Social Security disability determinations that was inconsistent with applicable law). This is not to say that all or even most of the class members who were denied coverage for physical therapy as a result of the intermediaries' inflexible and arbitrary practices ought to have received coverage. However, the Secretary cannot permit his intermediaries to use blanket rules not supported or authorized by any applicable law or regulations to deny what otherwise might be meritorious claims. The various arguments offered by the Secretary in support of the intermediaries' practices are unpersuasive and unsupported by the record of this case, In his Post-Trial Memorandum (filed July 13, 19B4) at 20? & n 7 the Secretary argues that physical1 therapy benefitsi are not available for pattients in the "non-weight bea7ring" stage of rehabilitation and for amputees who have not yet received prostheses, because such patients do not require daily thcratpy and because Pars B of Medicare may provide coverage for three days a week of therapy for patients who have purchased this optional health insurance. For one thing, the intermediaries' presumption that such patients never require skilled physical therapy on a daily basis is 09B6, Commerce Clearing Houset Inc.
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S. HRG. 100-69 CATASTROPHIC HEALTH
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CONTENTS Opening statement by Senat
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2 Second, I think the private insur
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4 So the question before us is how
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6 the elderly, long-term health car
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8 ments for our retirement. I might
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10 Mrs. YELINECK. Well, it would be
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12 As I understand it, you have not
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14 Mrs. YELINECK. One does not expe
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16 Senator BURDICK. Well, thank you
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18 Mrs. YEL.INECK. No. I started ou
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20 Therefore-I am supposed to take
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22 Chairman MELCHER. Well, I am ple
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24 month. Let us assume it costs $1
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26 STATEMENT BY SENATOR PETE WILSON
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28 Mrs. RIEGER. We have; we have wo
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30 Four years ago this August was w
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32 she has only 50 percent vision i
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34 Senator HEINZ. So it is both a p
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36 rich. Indeed, in the academic co
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38 pointedly in the comment from Mr
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40 finding out is that it is very l
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42 industry's role in providing cat
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44 Senator HEINZ. So things are wor
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46 Chairman MELCHER. In exactly the
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48 plement policy, what should that
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50 - 2 - I am Robert Shapland, Vice
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52 - 4 - CATASTRIPC PROTECTION IiDE
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54 -6- MiCIGAP INSJRANCE: A RPL1C/P
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56 To ensure that all of these cont
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58 - 10 - The HJAA also endorses Me
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60 - 12 - Finally, given that Congr
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62 - 14 - A recent HLAA survey of o
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64 Chairman MELCHER. Senator Heinz.
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66 Mr. SHAPLAND. I think we are in
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68 Those problems are real problems
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70 Mr. SHAPLAND. Oh, no. There are
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72 comprehension, and it is growing
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74 that educational process, and we
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76 So we have supported and activel
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78 Mr. SHIAPLAND. How much would nu
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80 rently being offered by the indu
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82 Recently, Karri Lynn has started
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84 Mr. Chairman and Members of the
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86 standards for voluntary certific
Page 91 and 92: 88 non-group subscribers of reporti
Page 93 and 94: 90 We believe a new federal program
Page 95 and 96: 92 However, public awareness is nee
Page 97 and 98: 94 Item 3 Testi~ony of GAIL SHEARER
Page 99 and 100: 96 to Secretary Bowen's proposals c
Page 101 and 102: 98 -4- most-states do not monitor t
Page 103 and 104: 100 Catastrophic Protection within
Page 105 and 106: 102 - a - participants and in part
Page 107 and 108: 104 - 2-- Consumers Union suV orts
Page 109 and 110: 106 29), but fails to acknowledge t
Page 111 and 112: 108 explore all alternatives to lon
Page 113 and 114: 110 adds to the complexity of Medic
Page 115 and 116: 112 - 10- Consider first the propos
Page 117 and 118: 114 - 12- insurance premiums and me
Page 119 and 120: Consunmer Unon Pubtishcr of Consume
Page 121 and 122: FOR RELEASE AT 9:00 P.M. H2ST) TUES
Page 123 and 124: 120 Itema I CENTER FOR MEDICARE ALw
Page 125 and 126: Page 3 122 aide services, however,
Page 127 and 128: Page 5 state treasuries." 124 Judge
Page 129 and 130: 126 462 6485 New Developments 10,05
Page 131 and 132: 128 462 6-85 New Developments 10,05
Page 133 and 134: 130 462 6-85 New Developments 10,05
Page 135 and 136: 132 10,930 New Developments tI.PZ ;
Page 137 and 138: 10,932 134 New Davelopments 492 346
Page 139 and 140: 136 10,934 New Developments It! ;6
Page 141: 10,936 138 New Developmenlt I. Thc
Page 145 and 146: 10,940 142 New Developments i92 586
Page 147 and 148: ATroR EYS -HARLES C. -ULiIN JUDITH
Page 149 and 150: 146 reformed its decision-making pr
Page 151 and 152: 148 : 14 2i57 New Developments 13,1
Page 153 and 154: ~ 150 a>, rsn Cdw ~w (e d rum 0A7,.
Page 155 and 156: 152 All Of these figures are based
Page 157 and 158: 154 The requirements of this Act sh
Page 159 and 160: 156 Drefting Note: Where the word "
Page 161 and 162: 158 (b) The issuance of the group p
Page 163 and 164: 160 (2) Contain a provision establi
Page 165 and 166: 162 and competitive reasons. It is
Page 167 and 168: 164 -13- E. Affordability of Long T
Page 169 and 170: NAIC LTC ADVISORY COMMITEE EXPOSURE
Page 171 and 172: Setinzn IS. Poicyx D~efinitieno aid
Page 173 and 174: 170 3. The term "noncancellable' ma
Page 175 and 176: 172 extension of benefits beyond th
Page 177 and 178: artinM B Requirmnts for Rplnmacwt 1
Page 179 and 180: 176 The above "Notice to Applicant"
Page 181 and 182: (pinnal Rasting &mdsninn 178 Benefi
Page 183 and 184: APPEMI!X B 180 OCWARISCN OF lVLCY i
Page 185 and 186: COMPAIeSON OF LOtG TEIM CoAt PfLtCI
Page 187 and 188: COMPABI:SZN OF LC#C TE" CAiE -OLICI
Page 189 and 190: COWaPAISON Of LOSt TERM CARE POLICI
Page 191 and 192: cowRiiSOi or touTE reM CasE nOuczcS
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COGPARISON OF LONG TERM CARE POLICI
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SOME BASIC THINGS YOU SHOULD KNOW M
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Private health insurance is availab
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WHAT MEDICARE PART B PAYS 196 MEDIC
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EXPENSES NOT COVERED BY MEDICARE Me
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HEARING - U.S. Senate Special Committee on Aging

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