Thursday, November 1, 2012

Medicare changes policy on "Improvement Standard"

By Joseph S. Karp

Florida Bar Certified Elder Law Specialist
Nationally Certified Elder Law Attorney
Florida and New York Bar
A sweeping change in Medicare policy may greatly help beneficiaries with chronic conditions who need skilled nursing and rehabilitation.  
In the past, Medicare would continue to cover skilled nursing care and short-term rehabilitation, like physical and speech therapy, only if the patient demonstrated that he had the potential to improve as a result of treatment. Obviously, those with chronic conditions like Alzheimer's Disease, heart disease, Parkinsons, Lou Gehrigs disease, arthritis - in other words, those who could not meet the so-called improvement standard -- were most impacted by this rule. (In fact, the so-called "improvement standard" was technically never a part of Medicare law; it had simply become the de facto standard used by Medicare decision makers.)
Now, a federal court has ruled that the improvement standard cannot be used to deny Medicare coverage for skilled nursing care and rehabilitation. The settlement in the class action lawsuit Jimmo v. Sibelius requires Medicare to cover skilled nursing and therapy even if it just maintains a person's medical condition or prevents further deterioration.  The proposed settlement was reached in federal district court on Oct. 16, 2012.
However, it's critical to note these important caveats: 
  1. The case does not change the maximum number of days of skilled care Medicare covers per benefit period. Medicare will pay 100% for a maximum of 100 days, and only if it follows a hospital stay or stay in a rehab facility.
  2. The case does not impact whatsoever on long-term, custodial nursing care, which is still not covered by Medicare, but may be covered under certain circumstances and with proper planning byFlorida Medicaid.
Details on the Medicare rule change here.

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