Introduction
The Medicare Advocacy Project, initiated by the Alzheimer's Association in collaboration the American Bar Association's Commission on Legal Problems of the Elderly, was developed to respond to various problems encountered by Medicare beneficiaries with Alzheimer's disease.
Project focus
Leslie B. Fried, Director of the Medicare Advocacy Project, works closely with the Alzheimer's Association public policy staff on the identification of Medicare trends, problems and patterns of recurring issues, and assists with the development of appropriate federal policy positions related to Medicare and health care delivery. Leslie does not represent individual clients but is a resource to provide research and support to local chapters and attorneys who handle Medicare issues.
The Medicare Advocacy Project has focused on several areas where there is a pattern of denials or reductions of payment or services for people with Alzheimer's disease:
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Coding and reimbursement for Alzheimer care
The most appropriate code for diagnosis and management of Alzheimer's disease is 331.0, which is reimbursed at the usual Medicare rate of 80 percent. Alzheimer's can also be billed under diagnostic code 290 (presenile dementia), an older category that falls under the mental health classification. But because Medicare, like many private health insurance plans, reimburses mental health care at 50 percent, bills submitted under the 290 code are reimbursed at the lower rate. The 331.0 code should be used to ensure appropriate reimbursement.
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Physical, occupational and speech therapies
In one of its first significant victories, the Medicare Advocacy Project won reversal of a long-standing policy that automatically denied reimbursement for rehabilitative services for beneficiaries who had been diagnosed with dementia. In the fall of 2001, Medicare issued a program memorandum prohibiting denial of these services based exclusively on a dementia diagnosis. The reversal hinged on the recognition that health care professionals now can often diagnose dementia in its earliest stages, when some individuals can derive significant benefit from rehabilitative services. Payment for medical services and procedures will now be determined on a case-by-case evaluation of an individual's needs and capabilities rather than solely on a dementia diagnosis.
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Psychiatric and mental health services
Medicare often denies mental health claims for beneficiaries with a primary or secondary diagnosis of dementia. These claims should not automatically be rejected, but should be evaluated and reimbursed on a case-by-case basis. Individuals with Alzheimer's may develop treatable mental illnesses such as depression that should be covered by Medicare. Medicare pays mental health claims at 50 percent rather than the 80 percent rate for other conditions, so allowable mental health services will be reimbursed at 50 percent.
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Home health care
Only Medicare beneficiaries who are "homebound" are eligible for Medicare home health care benefits. Medicare's definition of "homebound" has always been extremely strict, stipulating that leaving the home must involve "considerable and taxing effort." As of December 2000, the application of the definition was broadened to permit some individuals who attend adult day care to qualify as homebound if their day care program meets certain guidelines.
The Medicare Advocacy Project is committed to working with local Alzheimer's Association chapters on all Medicare problems. If you have issues that need to be addressed by this project, contact your local chapter for more information.
Medicare topic sheets
Through its Medicare Advocacy Project, the Alzheimer’s Association has developed several topic sheets describing Medicare benefits.
