Over the past year, there have been some significant changes in Medicare coverage for individuals in skilled nursing facilities. Previously, if someone was admitted to the hospital and required skilled nursing or rehabilitative services, Medicare would stop paying for those services based on an “improvement” standard. In other words, if continued services would not effectively improve the patient’s condition, Medicare coverage would cease and the individual would be either discharged or subject to private pay.
That standard has now changed. Pursuant to a settlement agreement approved on January 24, 2013, in Jimmo v. Sebelius, a federal district court case, the “improvement” standard can no longer be used to deny Medicare coverage in skilled nursing facilities. In accordance with the Jimmo v. Sebelius settlement agreement, the Centers for Medicare and Medicaid Services have agreed to issue revised portions of the relevant program manuals used by Medicare contractors, in order to clarify that coverage of skilled nursing and skilled therapy services does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care. Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition or to prevent or slow further deterioration of the patient’s condition.
With the average cost of nursing care nearing $8,000 per month, improper denial of Medicare coverage is financially burdensome. Additionally, the notice of termination of Medicare coverage must be contested in a very short timeframe. If you or a loved one receives a notice terminating Medicare coverage in a skilled nursing facility, the law offices of Barberi Law can help.