A Therapist's Guide to Laws and Regulations in Dementia Care

At Dementia Care Specialists, we promote best abilities and quality of life for every individual at all stages of dementia.

Therapists have a unique role in facilitating these goals by performing functional cognitive assessments, determining the person’s remaining abilities, creating maintenance programs, and training care partners in the programs.

These services provide individuals with dementia with the ability to engage in activities of daily living and activities of interest at their highest practicable level of independence. They’ve also been documented in the Medicare regulations as a means to provide Medicare beneficiaries with chronic and progressive illnesses (such as Alzheimer’s disease) with an avenue to maintain function and prevent or slow deterioration.

However, for years Medicare had a policy of denying coverage to people with dementia and other chronic illnesses “on the grounds that the individuals are 'chronic and stable' and will not improve.”

Prior to 2001, Medicare intermediaries/contractors were automatically denying therapy services based solely on the ICD-9 codes for dementia.
 

Loosening denial practices


Medicare advocates took up the cause and successfully convinced the Centers for Medicare and Medicaid Services (CMS) to loosen Medicare’s denial practices for people with Alzheimer’s disease and other cognitive impairments.

In 2001, CMS issued Program Memorandum AB 01-135 [PDF] to address the issue.

An article on medicareadvocacy.org reports that effective on September 1, 2001:

“Medicare will not use the dementia diagnostic codes alone as a basis for determining whether Medicare covered services are reasonable and necessary.”

And, as a result of the memorandum:

“Medicare payment of covered medical services and procedures will be determined based on the individual assessment and needs of the beneficiary, rather than denied solely because of the dementia diagnosis.”


Jimmo v. Sebelius


Years after this memorandum was issued, advocates again questioned denial of services based on an “improvement standard.” Improved functioning is not a requirement of Medicare law, but it was still a standard often applied in coverage determinations.

As a result of advocacy efforts for Medicare beneficiaries with chronic and progressive illnesses, a federal judge approved a settlement agreement in the case of Jimmo v. Sebelius in January 2013. Plaintiffs in the case alleged that Medicare contractors were inappropriately applying an “Improvement Standard” when making claims determinations for Medicare coverage involving skilled care.

According to the fact sheet on the settlement:

“The settlement agreement is intended to clarify that when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration.”

Still enforcement of this rule continued to be inconsistent.

So in 2016, Chief Judge Christina Reiss, who oversaw the “Improvement Standard” case, released an Opinion and Order [PDF] that ordered the federal government, through the CMS, to comply with the Settlement Agreement that she had approved in 2013. [More details]

This Medicare benefit still requires vigilance by therapists, long-term care and assisted living communities, and home health agencies that are positioned to provide services for persons with dementia. If denial of services occurs, therapists and health care organizations must prepare to advocate for these beneficiaries.

Also: Search for laws and regulations in your area
 

The National Alzheimer’s Project Act


Recently, legislation has passed which further supports persons with dementia and their care partners.

The National Alzheimer’s Project Act (Public Law 111-375), passed unanimously by Congress in December 2010, was signed into law by President Obama in January 2011. It required the creation of a national strategic plan to coordinate Alzheimer’s disease efforts across the US government.

NAPA goals as of 2016:
  1. Prevent and effectively treat Alzheimer’s disease and related dementias by 2025.
  2. Enhance care quality and efficiency.
  3. Expand supports for people with Alzheimer’s disease and related dementias, and their families.
  4. Enhance public awareness and engagement.
  5. Improve data to track progress.
Read also: Kim Warchol’s response to NAPA
 

The IMPACT Act


In October 2014, the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) was passed.

The purpose of the IMPACT Act is to protect clients’ choice and to streamline service provision. According to CMS, the act requires standardized reporting of quality measures in areas such as function, cognition, skin integrity, major falls, patient preference, and medication reconciliation.

This act supports therapists’ use of standardized testing to determine functional cognition, facilitate remaining abilities based on a client’s preferences, and create plans to maintain function.

Read also: How Will the IMPACT Act Impact Your Dementia Care Community? and The Medicare IMPACT Act and Dementia Care
 

Join us!


Our mission at Dementia Care Specialists is to create and support a Dementia Capable Society. Therapists’ interventions can be vital to the well-being of persons with dementia and their care partners, and to our mission. Due to these laws and regulations, therapists have increased opportunities to serve persons with dementia, slow deterioration, and improve quality of life.

More information on how you can learn and implement best practices in dementia care: How do you improve quality of life for persons with dementia? Please share in the comments.
 
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