A Commentary on the Medicare Low Vision Rehabilitation Demonstration Project

Despite the best efforts of the Centers for Medicare and Medicaid Services (CMS) with regard to the field of visual impairment and blindness, and despite the concerted efforts of the members of the field to make the most of the Medicare Low Vision Rehabilitation Demonstration Project, there are intrinsic flaws in scope and design of the project that preclude its successful implementation and may even undermine the services that have been extended by Medicare to beneficiaries with visual impairments in the last decade. To set the stage and provide a context for this argument, we begin with some background information and a review of events leading up to the April 1, 2006 initiation of the five-year demonstration project. ORGANIZATION OF MEDICARE The Medicare system is currently administered by 16 regional carrier directors, who are responsible for regions that encompass from one to 12, not necessarily contiguous, U.S. states. Regional carriers have considerable autonomy in coverage decisions with respect to services for which CMS has no policy. Medicare billing is submitted through codes representing a disease, impairment, or treatment, which are specifically approved or not approved for reimbursement. REIMBURSEMENT FOR VISION REHABILITATION OUTSIDE THE DEMONSTRATION PROJECT Currently, 13 of the 16 regional carriers are known to be providing Medicare reimbursement for vision rehabilitation services performed by physicians or occupational therapists. Five are reimbursing in all of the states in their regions and eight in some of the states in their regions, for a total of at least 26 states. Some carriers have created local coverage policies while others simply follow the Program Memorandum of 2002, which provided guidelines for reimbursing vision rehabilitation services, as described further in the CMS Program Memorandum of May 2002 section of this essay. Regional carriers develop policies in response to requests for reimbursement for a particular service. If no provider in the region is billing for that service, the carrier is unlikely to have a stated policy. Furthermore, if a carrier reimburses for a particular service in any state in its region, it is likely that it will also reimburse for that service in its other states if requested. Therefore, when there is no record of vision rehabilitation services in a particular state being reimbursed, but its regional carrier reimburses for vision rehabilitation services in other parts of the region, the likelihood is that no providers are submitting billings for such services. To our knowledge, in every state in which a physician or occupational therapist has requested reimbursement for vision rehabilitation with reference to the May 2002 program memorandum, reimbursement has been forthcoming. BACKGROUND AND SEQUENCE OF EVENTS Mid-1990s: Existing services could not meet the need In the mid-1990s, existing state and agency services were unable to meet the rehabilitation needs of the emergent and ever-increasing population experiencing vision loss from age-related macular degeneration (AMD) for three main reasons. First, many state and private service agencies required recipients to be legally blind to qualify for Medicare-funded rehabilitation, whereas those with gradually progressing central vision loss from AMD require vision rehabilitation training long before their vision deteriorates enough to qualify as legal blindness. Second, most state and many private programs were designed to meet the educational and employment needs of younger individuals, whereas seniors with AMD have very different physical, ergonomic, and psychosocial comorbidities and rehabilitation needs and skills. Third, most programs were budgeted for a small number of clients, whereas the population of visually impaired seniors numbers in the millions. Gaining regional Medicare coverage for vision rehabilitation By demonstrating the fact that existing services could not meet vision rehabilitation needs, ophthalmologists successfully negotiated with the Medicare regional carrier directors in the mid-1990s to add codes for visual impairment to the list of impairment codes approved for rehabilitation services within the Medicare system. …