Medicare Coverage for Skilled Care Services: Knowing the Correct Standard and Your Rights

Have you, or has someone you know, ever been told that your loved one’s Medicare coverage for skilled care services will be stopping because they are either not improving, or are not likely to improve, from additional services?  Within the last month, we have repeatedly heard this from our clients.  We continue to hear this so much that we felt compelled to write this post, as a follow-up to our June 1, 2014 post, to reiterate what the Medicare laws and regulations actually state on this matter.

On January 24, 2013, a settlement in the case of Jimmo v. Sebelius, which was pending before the U. S. District Court for the District of Vermont, was approved.  Although three years have now elapsed since the law on this matter was settled and clarified, confusion, misinformation, and misapplication by, and among, Medicare contractors seems to remain.  The settlement made it clear that the “improvement standard” routinely used by Medicare contractors to determine whether Medicare coverage was available for skilled care services is NOT the appropriate standard.  Per the Jimmo settlement, the determining issue as to whether a Medicare recipient is entitled to Medicare coverage for skilled care services received in a skilled nursing facility (SNF), home health (HH), and outpatient therapy (OPT) in a long-term care facility (assuming all conditions of eligibility have been met) is dependent upon whether the services are necessary to maintain the individual’s condition or to prevent or slow their decline, and NOT whether the Medicare beneficiary will “improve.”  According to the federal government, this has always been the standard, and as such the Jimmo settlement was not a change in the Medicare laws and/or regulations.

The bottom line, quite simply, is that is important to know the correct standard and to know your rights.  Denials of coverage for skilled care services, when the “improvement standard” is used as opposed to the correct standard are appealable.  The Center for Medicare Advocacy       (www.medicareadvocacy.org)has extensive information regarding the correct standard, the Jimmo settlement, and “self-help” resources for the timely appeal of an “improvement standard” denial.

©Copyright 2016 by Constance Burnett Renzi. All rights reserved.

The Elder Law Center, P.C. (subsidiary of Mickey, Wilson, Weiler, Renzi & Andersson, P.C., http://www.mickeywilson.com) is located in Aurora, IL, Kane County, in the Chicago Western Suburbs, phone number: 630-844-0065.

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