Statement by APTA President on Proposed Legal Settlement of Medicare 'Improvement Standard' Case

October 24, 2012

APTA applauds the proposed legal settlement of the nationwide class action lawsuit directed toward ensuring Medicare coverage of reasonable and necessary therapy and nursing services for people with chronic and degenerative health conditions. The proposed settlement resolves a lawsuit (Glenda Jimmo, et. al vs. Kathleen Sebelius) under which plaintiffs alleged that the US Department of Health and Human Services, Medicare contractors, and administrative review boards were arbitrarily limiting coverage for patients who did not show long-term improvement in their conditions, even though official Centers for Medicare and Medicaid Services rules state these services should be covered.

Under this proposed agreement, Medicare would pay for skilled therapy and nursing services if they are needed to maintain the patient's current condition or prevent or slow further deterioration.

This policy aligns with APTA's long-held belief that determinations of whether physical therapy services should be covered under Medicare should be based on the unique condition and individual needs of each patient. This proposed settlement would enable millions of Americans who suffer from chronic and debilitating conditions, such as Alzheimer disease, multiple sclerosis, Parkinson disease, and spinal cord injury, to obtain Medicare coverage of physical therapy and other services that are medically necessary.

As highlighted in The New York Times, we strongly believe that allowing Medicare beneficiaries to receive physical therapy in skilled nursing facilities and home and community-based settings will result in significant cost savings in the long term, as well as help bolster the triple aim of health care reform to improve care for individuals, improve health for populations, and lower spending growth. Most important, this policy will help Medicare beneficiaries preserve quality of life and a level of independence.

APTA will continue its efforts to ensure access to appropriate physical therapy services. We also will work with the Centers for Medicare and Medicaid Services and its contractors to ensure accurate and fair incorporation of revisions to the current Medicare manuals and regulations that reflect this significant change. In addition, the association will continue to analyze the proposed settlement for potential impact on Medicare policies regarding the reporting of functional limitations on the claim for outpatient therapy and the requirement to complete a functional reassessment at defined intervals under the Home Health Part A benefit. APTA plans to actively educate members to ensure proper understanding and application of the newly revised Medicare regulations.

APTA has always believed patient needs should come first when determinations regarding health care are made. We are encouraged by this proposed settlement and its impact on the lives of individuals with chronic and debilitating health conditions.

APTA President Paul Rockar Jr, PT, DPT, MS 

CSM 2016