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

February 21, 2016

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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2016 Medicare Premiums, Deductible, and Co-Insurance Amounts At-a-Glance

January 14, 2016

Still sorting through the new Medicare premiums, deductible, and co-insurances for 2016?  Here is a link to a Medicare press release detailing the 2016 amounts.

Medicare press release:  https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-11-10.html

As set forth in the press release, most Medicare Part B recipients did not experience a change in their 2016 Part B premiums, as their premiums remain at $104.90 per month.  Some (approximately 30%), however, have experienced an increase in their 2016 Part B premiums, and must now pay a premium of $121.80 per month.  The press release further explains the 2016 premium increase for the 30% of beneficiaries, who are those who are not “held harmless” from premium increases when Social Security benefits remain unchanged.  All other Medicare premiums, deductibles, and co-insurance amounts for 2016 are increasing.  The following is an at-a-glance review of the 2016 numbers:

  • Basic Part B premium: $104.90/month (unchanged for those “held harmless”)
  • Part B premium for those not “held harmless”: $121.80
  • Part B deductible: $166 (was $147)
  • Part A deductible: $1,288 (was $1,260)
  • Co-payment for hospital stay days 61-90: $322/day (was $315)
  • Co-payment for hospital stay days 91 and beyond: $644/day (was $630)
  • Skilled nursing facility co-payment, days 21-100: $161/day (was $157.50)

Additionally, higher-income beneficiaries will pay higher Part B premiums, as follows:

  • Individuals with annual incomes between $85,000 and $107,000 and married couples (filing a joint tax return) with annual incomes between $170,000 and $214,000 will pay a monthly premium of $170.50 (was $146.90).
  • Individuals with annual incomes between $107,000 and $160,000 and married couples (filing a joint tax return) with annual incomes between $214,000 and $320,000 will pay a monthly premium of $243.60 (was $209.80).
  • Individuals with annual incomes between $160,000 and $214,000 and married couples (filing a joint tax return) with annual incomes between $320,000 and $428,000 will pay a monthly premium of $316.70 (was $272.70).
  • Individuals with annual incomes of $214,000 or more and married couples (filing a joint tax return) with annual incomes of $428,000 or more will pay a monthly premium of $389.80 (was $335.70).

Note:  The premiums differ for beneficiaries who are married and lived with their spouse at any time during the year, but file a separate tax return from their spouse. For additional information regarding those premium amounts, see the press release noted above.

Our legal team is available for consultations with Illinois residents regarding estate planning (Wills and Trusts), durable powers of attorney (life care planning), probate and/or trust administration, guardianships, special needs planning, Medicaid for long-term care, and/or other elder law issues. To schedule an appointment contact our office at 630-844-0065. The Elder Law Center is located in Aurora, IL, Kane County, in the Chicago Western Suburbs.

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Many Still Unaware That Medicare Coverage Is Now Available for Chronic Conditions

June 1, 2014

If you are a Medicare beneficiary receiving skilled care for a chronic condition, you no longer have to show improvement in order to have the care covered, but your provider (such as a doctor, home care agency, or nursing home) may not know this. Even though a recent lawsuit settlement mandated a nationwide educational campaign for providers, many are still refusing to provide needed treatment, claiming that Medicare will not cover it.

For about 30 years, home health agencies and nursing homes that contract with Medicare have routinely terminated the Medicare coverage of a beneficiary who has stopped improving, even though nothing in the Medicare statute or its regulations says improvement is required for continued skilled care. Under a settlement agreement in Jimmo v. Sebeliusthe federal government agreed to update Medicare rules to require that Medicare cover skilled care as long as the beneficiary needs skilled care, even if it would simply maintain the beneficiary’s current condition or slow further deterioration.

The policy shift affects beneficiaries with conditions like multiple sclerosis, Alzheimer’s disease, Parkinson’s disease, ALS (Lou Gehrig’s disease), diabetes, hypertension, arthritis, heart disease, and stroke. In addition, under the settlement Medicare beneficiaries who received a final denial of Medicare coverage after January 18, 2011 (the date the lawsuit was filed) are entitled to a review of their claim denial.

The government launched an educational campaign in January to explain the settlement and the new rules to Medicare providers like home care agencies and nursing homes, but according to a Reuters article, many providers remain unaware of what is covered or how to bill Medicare for the services. The campaign was not aimed at beneficiaries, so not all Medicare beneficiaries are aware of the rules and that they can fight a denial of coverage.

Reuters focuses on one beneficiary, Robert Kleiber, 78, who receives weekly visits from a physical therapist to alleviate symptoms of his Parkinson’s disease. Kleiber’s wife recently learned that the treatments should be covered under Medicare’s new rules but so far she has been unable to convince the home health care provider of this.

If you experience problems with a Medicare provider, the Center for Medicare Advocacy has several self-help packets explaining how to appeal improvement standard denials.

For the Reuters article, click here.

To learn more about Medicare, click here.

To discuss elder law issues with an attorney, please call the Elder Law Center at 630-844-0065 or contact us via email. The Elder Law Center is located in Aurora, IL, Kane County, in the Chicago Western Suburbs.