Medicare to End 'Improve or You're Out' Standard for Coverage of Skilled Services

In a major change in Medicare policy, the Obama administration has provisionally agreed to end Medicare’s longstanding practice of requiring that beneficiaries with chronic conditions and disabilities show a likelihood of improvement in order to receive coverage of skilled care and therapy services. The policy shift will affect beneficiaries with conditions like multiple sclerosis, Alzheimer’s disease, Parkinson’s disease, ALS (Lou Gehrig’s disease), diabetes, hypertension, arthritis, heart disease, and stroke. (See companion article, "Who Will Benefit From the New Medicare Policy Change?".)

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.  Advocates charged that Medicare contractors have instead used a covert "rule of thumb" known as the “Improvement Standard" to illegally deny coverage to such patients. Once beneficiaries failed to show progress, contractors claimed they could deliver only "custodial care," which Medicare does not cover.

In January 2011, the Center for Medicare Advocacy and Vermont Legal Aid filed a class action lawsuit, Jimmo v. Sebelius, against the Obama administration in federal court aimed at ending the government’s use of the improvement standard.  After the court refused the government’s request to dismiss the case, and the administration lost in similar individual cases in Pennsylvania and Vermont, it decided to settle. 

As part of the proposed settlement, which the federal judge must still formally approve, Medicare will revise its manual that contractors follow to clarify that Medicare coverage of skilled nursing and therapy services “does not turn on the presence or absence of an individual’s potential for improvement” but rather depends on whether or not the beneficiary needs skilled care, even if it would simply maintain the beneficiary's current condition or slow further deterioration.

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 Jimmo settlement provides hope for thousands of older and disabled people with chronic and long-term conditions who will now have a fair opportunity to get access to Medicare and necessary health care,” Judith Stein, Executive Director of the Center for Medicare Advocacy, told ElderLawAnswers.   

In an article about the accord, the New York Times notes that Medicare’s coverage of skilled care for beneficiaries with chronic conditions “could also provide relief for families and caregivers who often find themselves stretched financially and personally by the need to provide care.”

Although the Times quotes a trustee of the Medicare program that the change will cost Medicare more money, it could also save some money because physical therapy and home health care may help keep beneficiaries out of more expensive institutions like nursing homes and hospitals.   

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The Law Offices of Jeremy W. Howe, LTD. are ElderLaw attorneys in Rhode Island who specialize in wills and trusts, estate planning, guardianship, probate, and Veterans Aid and Attendance Benefits.

They also are Newport Rhode Island Divorce Lawyers, Attorneys, Mediators, and Arbitrators providing services for family law issues such as divorce, child custody and visitation, support, and military family law.

Call them today at 401-841-5700 or visit them on the web at http://www.CounselFirst.com.

Contact Your Legislature about the "Improving Access to Medicare Act"

This information was passed along by Kathy Heery, RN, MSN, Geriatric Care Manager, as a member of the Kent County Senior Provider Network:

Published 20-Apr-2011 by Brian Stever in Latest News

New legislation will allow a resident that is held in "observation" to
have this time counted toward their required Medicare 3 day stay.

The Improving Access to Medicare Act would allow beneficiaries kept in a hospital for "observation" to qualify for Medicare Part A coverage of a
subsequent stay in a skilled nursing facility (SNF). The bill would count
any time spent in observation toward the 3-day stay requirement.
Increasing numbers of beneficiaries are disqualified from Part A coverage
of their SNF stay because they were held for observation rather than
admitted as an inpatient.

Please Contact Congress and ask your legislators to support this important legislation so it can move to the floors of the U.S. Senate and House of Representatives.

Please follow the link to tell your legislators how important that this
legislation is.

http://capwiz.com/leadingage/issues/alert/?alertid=42264501


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The Law Offices of Jeremy W. Howe, LTD. are ElderLaw attorneys in Rhode Island who specialize in Wills and Trusts, Estate Planning, Guardianship, Probate, and Veterans Aid and Attendance Benefits.

They also are Newport Rhode Island Divorce Lawyers, Attorneys, Mediators, and Arbitrators providing services for Family Law issues such as Divorce, Child Custody and Visitation, Support, and Military Family Law. 

Call them today at 401-841-5700 or visit them on the web at http://www.CounselFirst.com.