HEARING - U.S. Senate Special Committee on Aging

148
: 14 2i57 New Developments
13,115
included as part of a periedic Medivarc Part It
noit ic) is left to the defendant s discretion prosided.
however, that such noticc be by first class
mail and contain a response sheet and a
stamped, self-addressed envelope to facilitate
reply.
B. In addition to the personalized notice
described above, the defendant will publish a
generalized notice to the plaintiff class in five
newspapers or other publications having general
distribution within the State of Connceticut, at
least two vi which must be publications whose
target audience is the elderly.
C. The sutice to plaintiffs described above
-hall inform plaintiff, that:
i. The United States District Court in Fox v.
Bowsen. Civil Action No. H 78-541 (JAC), has
determined that the Secretarv of Health and
Human Services and his agents have acted iMCeitaliy
between Octtewr 1978 and April 1986 hb
arbitrarily denying Medicare skilled nursing
tacilitv benefits to patients receiving lailv phy'-
,al thcraps treatment-
2 Any Connecticut resident who se:s ienied
Medicar, slilled nursing facility henefits
hetec-ri October 1978 and the present. despite
hi:. r h,- rereipt of daily physic al therapy
reatmeot. is a member of the plaintiff class,
andi! i- en ictad to have his or her claim cedetermined
Iv the defendant.
3. Any member of the plaintiff class. or his or
her reprcscniative, desiring such a redetermination
should indicate that fact on the respitnrc
sheet enclosed with the notice, and rcturn the
response sheet to the defendant in the selfaddressed
envelope enclosed.
D. The response shirt shall indicatcethc plaintiff's
name and address, the name of the skilled
nursing iacility and] the dates of skilled nursing
facility care at issut.
E. In making the redetermination, the defendant
will ensure that every plaintiff receives an
individualized assessment of his or her entitle.
ment to Medicare skilled nursing facility coverage
in ic orhl;,nni with the Memurandum of
l)Dci.iun ivued bs the court on April 23. 1986.
Slecitjircalie, the lefenid ia t silt adhere ii the
oioloing turm,.
I. Th- defendant will nut employ arhitrary
presutnptiins or rules of thumh in urder to den%
coverage such presumptions include the defendant's
pcactice of denying skilled nursing facilits
(tst-rage:
p lot t.irot. r ttuirinc nmaintenanci t Iherap:
h ior i ,t- n vsghi searmin thirapi a dtninis
teredl to fracture patients:
M oicr and Medicin d. mGuiden atiiesl
Medicare and Medicaid Guide
1. ifir patients who can ambulate 50 feet with
sulurvTi ilOr
e. fur amputees who have nut been fitted with
prostheses;
f. for those Iatients who rcquire daily skilled
physical therapy for a lpriod in excess of two
weeks.
2. The certification and orders of the attending
physician will be given due consideration In
any redetermination where the defendant denies
Medicare skilled nursing facility coverage
despite the attenlding phvsicians certification
and orter that dlail physical therapy be given,
the defentdant shall describe with particularity
why the care involved is nut covered by the
Me dicarv program.
F. Copies of all redietermination decisions
shall be sent to plaintiffs counsel, and toi the
special master dccribed in Section 11. C. helow.
IL. Pruspectiie Relief
A. The defendant sill provide written notice
to all skilled nursing facility pruviders ( provid.
ers") of scrvices and all intermediaries, informing
them that.
I. The United States District Court in foe *-
Bu-en. Civil Actiot Nu H 78-541 (JAC). has
driermintid that the Sccretary of Health and
Human Surt icea and his agents have acted iiec
gally hetween October 1978 and 1980 in arbitrarily
denying Medicare skilled nursing facility
benefits to patients receiving daiy! phi ical
therapy treatments.
2. In making such determinations, providers
and intermediaries shall henceforth ensure that
every plaintiff receive an individualized assessment
of his or her entitlement to Medicare
skilled nursing coverage. Specifically, providers
and intermediaries sill adhere to the follosing
norms
a. Providers and intermediarics will not
emplu- arbitrarc presumptions or rules of
thumb to deny coverage: such presumptions
include providers and intermediaries prac.
tier of denying skilfei nursing facility cover-
1. to palicist rcqsui iong maintenaitce therapy;
2. for non-weieht bearing therapy adminis,
treed to frac ure patients;
3 for passive Ta lice tof m ii iin a ti i tie s
4. for patients who can ambulate 50 feet with
superisiont;
Ifm amo muiieS I.l, h;,is 1,: isr ii ittied with
te ior th os p atents ssh o retquire t lil kttil(
ph yvic:l theralw fii .1 rio"rt in esies' .ii Swt
36.030