INDUSTRY INSIGHT
LONG-TERM CARE
SPONSORED CONTENT
DON’T LET HEALTH CARE PROVIDERS USE THE
IMPROVEMENT STANDARD TO DENY MEDICARE COVERAGE
H
ave you or a loved one been denied Medicare-covered
services because you’re “not improving”? Many health care
providers are still not aware that Medicare is required to
cover skilled nursing and home care, even if a patient is
not showing improvement. If you are denied coverage based on this
outdated standard, you have the right to appeal.
For decades, Medicare, skilled nursing facilities, and visiting
nurse associations applied the so-called “improvement” standard to
determine whether residents were entitled to Medicare coverage of
their care. The standard, which is NOT in Medicare law, only permitted
coverage if the skilled treatment was deemed to contribute to
improving the patient’s condition, which can be difficult to achieve
for many ill seniors.
Three years ago, in the case of Jimmo v. Sebelius, the Centers for
Medicare & Medicaid Services (CMS) agreed to a settlement in which
it acknowledged that there is no legal basis to the “improvement”
standard and that both inpatient skilled nursing care and outpatient
home care and therapy may be covered under Medicare, as long as
the treatment helps the patient maintain his or her current status or
simply delays or slows their decline. In other words, as long as the
patient benefits from the skilled care, then the patient is entitled to
Medicare coverage.
Medicare will cover up to 100 days of care in a skilled nursing
facility following an inpatient hospital stay of at least three days and
YOUR SYMBOL OF PROTECTION
Are you worried about losing your home
or life savings to the cost of long term care?
Are you a veteran or spouse of a veteran?
If the answer is yes, we can help.
What's at risk?
Only everything you own
Protecting People, Property, & Life Savings
724-942-6200
PittsburghElderLaw.com
will cover home-based care indefinitely if the patient is homebound.
Days 1-20 are paid in full under Medicare and days 21-100 come with
a co-pay of $167.50 per day. A Medigap supplement or Medicare
Advantage plan can provide varying degrees of co-pay coverage.
Unfortunately, despite the Jimmo settlement, the word hasn’t
gotten out entirely to the organizations and providers that actually
apply the rules. As a result, the Jimmo plaintiffs and CMS have now
agreed to a court-ordered corrective action plan, which includes the
following statement:
The Centers for Medicare & Medicaid Services (CMS) reminds the
Medicare community of the Jimmo Settlement Agreement (January
2014), which clarified that the Medicare program covers skilled
nursing care and skilled therapy services under Medicare’s skilled
nursing facility, home health, and outpatient therapy benefits when
a beneficiary needs skilled care in order to maintain function or to
prevent or slow decline or deterioration (provided all other coverage
criteria are met). Specifically, the Jimmo Settlement required manual
revisions to restate a “maintenance coverage standard” for both skilled
nursing and therapy services under these benefits:
Skilled nursing services would be covered where such skilled nursing
services are necessary to maintain the patient’s current condition or
prevent or slow further deterioration so long as the beneficiary requires
skilled care for the services to be safely and effectively provided.
Skilled therapy services are covered when an individualized
assessment of the patient’s clinical condition demonstrates that the
specialized judgment, knowledge, and skills of a qualified therapist
(“skilled care”) are necessary for the performance of a safe and
effective maintenance program. Such a maintenance program to
maintain the patient’s current condition or to prevent or slow further
deterioration is covered so long as the beneficiary requires skilled care
for the safe and effective performance of the program.
The Jimmo Settlement may reflect a change in practice for those
providers, adjudicators, and contractors who may have erroneously
believed that the Medicare program covers nursing and therapy
services under these benefits only when a beneficiary is expected to
improve. The Settlement is consistent with the Medicare program’s
regulations governing maintenance nursing and therapy in skilled
nursing facilities, home health services, and outpatient therapy
(physical, occupational, and speech) and nursing and therapy in
inpatient rehabilitation hospitals for beneficiaries who need the level
of care that such hospitals provide.
While this statement doesn’t change the rights Medicare patients
have always had, it should make it somewhat easier to enforce them.
If you or a loved one gets denied coverage because a patient is not
“improving,” then you need to seek the assistance of an experienced
Elder Law Attorney.
Colleen Bratkovich is a senior associate attorney with
Zacharia Brown P.C. We are one of the oldest and most
established elder law firms in western Pennsylvania. Our
practice focuses on Medicaid Eligibility, Veterans Benefits
Planning, Elder Law and Estate Planning, including wills,
powers of attorney, living wills, and trusts. Our office
locations include McMurray, McKeesport and Wexford, PA
along with Bradenton and Pompano Beach FL.
Phone: (724) 942.6200.
Website: www.PittsburghElderLaw.com.
E-mail: [email protected]
PETERS TOWNSHIP
❘
APRIL/MAY 2018
85