October 2005 • Volume 99Number 10

Comment

Medicare Coverage for Orientation and Mobility Services

As this article is being written, a five-year national demonstration project to provide Medicare coverage for orientation and mobility (O&M) and other vision rehabilitation services is under review by the U.S. Office of Management and Budget and is scheduled to begin in early 2006. Under the demonstration project, qualified O&M specialists and other vision rehabilitation professionals will be able to provide medically necessary services to Medicare beneficiaries under the general supervision of an eye care physician, and these services will be reimbursable by Medicare. (The specific sites for the demonstration project have yet to be determined.) Services may be provided either in a professional facility or in the client's home and environs. This is a huge step forward in the longtime quest for third-party health insurance coverage for the services of vision rehabilitation professionals.

The demonstration project is intended to provide data to the Centers for Medicare and Medicaid Services (CMS), the federal agency that administers the Medicare program, on such issues as the scope and nature of vision rehabilitation services provided, the benefits to patients, and the role of vision rehabilitation professionals in the provision of care. For this reason, it is important for professionals to participate as much as possible to show their expertise in the field of rehabilitation and the value of the work they perform.

Why Medicare?

Medicare coverage will increase access to services and continuity of care for consumers with vision impairment. Medicare provides health insurance for the vast majority of older Americans, as well as for some younger Americans with disabilities. Insurance coverage is the grease in the health care system; without it, services may be unobtainable or unaffordable for people who need them. Physicians may be unaware of services that are not covered by insurance and may not refer patients to them.

Medicare pays for medically necessary rehabilitation for most physical injuries and impairments. Originally, however, rehabilitation for vision loss was not explicitly covered by Medicare when it was created in 1965. A program memorandum issued in May 2002 by CMS clarified the situation by informing Medicare carriers that they should no longer automatically deny claims for vision rehabilitation services. Although the program memorandum was definitely a step in the right direction, it did not constitute "national coverage policy" and thus did not ensure uniform coverage across all states. The program memorandum also did nothing to allow reimbursement for the services of specially trained vision rehabilitation professionals--O&M specialists, vision rehabilitation therapists, and low vision therapists. In fact, a recent CMS ruling explicitly prohibits reimbursement for rehabilitation services by providers other than occupational or physical therapists, even as "incident to" services under a physician's direct supervision. Although the vision community as a whole is working to reverse the CMS rule, the rule will not affect the demonstration project or the ability of vision rehabilitation professionals to work under the "general supervision" of an ophthalmologist or optometrist, which provides a higher level of autonomy than is provided under the "incident to" category.

Moving toward coverage

The movement to improve Medicare coverage for the services of vision rehabilitation professionals gained impetus in 1999, with a growing coalition of professional and consumer organizations in the vision, aging, and health care fields, led by the National Vision Rehabilitation Association. Bills to establish the Medicare Vision Rehabilitation Services Act, introduced in the 106th and 107th Congresses, garnered considerable support, as well as some opposition, but did not pass. In the 108th Congress, the bill's original cosponsors--Reps. Mike Capuano (D-MA) and Mark Foley (R-FL) and Sen. John Kerry (D-MA)--were joined by Sen. John Sununu (R-NH), who became its leading champion. The provisions of the bill were included in the Medicare Prescription Drug and Modernization Act (MMA) that passed the Senate late in 2003. The provisions were not included, however, in the House version of the MMA or the final bill that was passed by Congress and signed into law.

At that point, the congressional champions of vision rehabilitation introduced new language calling for a Medicare vision rehabilitation demonstration project that was included in the omnibus appropriations bill. That language was incorporated into the final omnibus legislation, which funded many government programs for fiscal year 2004. Since that time, CMS has been studying ways to implement the demonstration project and develop a plan to carry it out.

Significance and next steps

As the first time that vision rehabilitation professionals have been explicitly recognized by Medicare, the demonstration project offers an outstanding opportunity to show that O&M, vision rehabilitation therapy, and low vision therapy services fit naturally in the Medicare context and that these specialized professionals are key members of the vision rehabilitation team. At the same time, due to cost and budgetary considerations, there are concerns about the limitations inherent in the demonstration project as it is currently written, including the relatively few number of states that will be selected, and limitations on the hours of treatment to be provided. For these reasons, the advocates are currently working with CMS and congressional supporters to clarify and correct flaws in the demonstration project and will continue to work to improve the project once it begins. It will be extremely important for vision rehabilitation professionals to get involved in the demonstration. O&M specialists--or the agencies they work for--will need to establish formal relationships with eye care physicians who will be responsible for developing the vision rehabilitation plan of care, supervising service provision, and billing Medicare. Service providers will have to learn to deliver and document their services according to Medicare procedures and codes. Vision rehabilitation agencies and professionals will need to market their services, so that other health care providers, consumers, and their families are aware of the benefits of specialized services and the expanded Medicare coverage available in their states.

A successful demonstration project will give strong impetus to the next step--persuading Congress to make the services of vision rehabilitation professionals a permanent part of Medicare. Both the efforts of the Academy for Certification of Vision Rehabilitation and Education Professionals to maintain rigorous credentialing standards in order to ensure that certified professionals are highly qualified, and ongoing activities to increase the supply of university-trained specialized vision rehabilitation professionals, go hand-in-hand with the advocacy initiative that has produced the Medicare demonstration project.

Much has been accomplished; much remains to be done. The lack of licensure for vision rehabilitation professionals in any state remains a major stumbling block. O&M specialists have participated in several efforts in recent years to obtain licensure--in Tennessee, Pennsylvania, and New York, for example, and a New York coalition continues to work toward passage of a licensure bill. In the absence of licensure, national certification assumes an even more important role in assuring the public, other health care providers, and Congress of the qualifications of vision rehabilitation professionals. However, achieving state licensure will ultimately be necessary before Congress will consider putting vision rehabilitation professionals providers fully on a par with other therapists who are recognized by Medicare.

The energy of O&M specialists and their colleagues in vision rehabilitation therapy and low vision therapy and their dedication to increasing access to quality services have helped move the field to the brink of achieving a major, longstanding goal: bringing vision rehabilitation services into the health care mainstream and securing third-party reimbursement for these vital services.

Lorraine Lidoff, M.A., former executive director, National Vision Rehabilitation Association; e-mail: <llidoff250@comcast.net>.

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