Q: Is it true that if I go into a skilled nursing facility (SNF) after a qualifying hospital stay, there’s a chance that Medicare could refuse to provide coverage for my care if I don’t show signs of improvement, or don’t have the ability to get better?
A: While Original Medicare may have many gaps in coverage that can leave you exposed to financial risks, there has been much confusion, even among Medicare providers, contractors, and adjudicators, about whether Medicare provides coverage for skilled services care when a beneficiary does not show signs of improvement, or is unable to improve.
On January 18, 2011, a class action lawsuit was filed in Vermont to challenge “Improvement Standards” that had been used to deny coverage for some Medicare beneficiaries who needed skilled care.
Although it was not determined that any wrongdoing had taken place, a 2013 settlement agreement in the case of Jimmo v. Sebelius provided clarification on Medicare’s policy on this issue, and an educational campaign was launched.
In 2016, the plaintiffs in that case filed a motion to enforce the Settlement Agreement. They argued that very little had changed in the way claims were being processed because the educational campaign was so confusing and inadequate.
The Federal court instructed CMS (the Centers for Medicare & Medicaid Services) to issue a Corrective Statement to disavow the use of an “Improvement Standard” for Medicare coverage, and provide further clarification and education as part of a Corrective Action Plan that must be fully implemented by September 4, 2017.
Medicare claims for skilled services cannot be denied if the determination
is based solely on one’s inability to improve.
More specifically, here is what you need to know…
Skilled nursing services and skilled therapy services are covered for Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facilities (IRF), Home Health care (HH), and Outpatient Therapies (OPT) when they are needed to maintain the patient’s current condition, or prevent, or slow further deterioration, as long as the beneficiary requires skilled care for the services to be safely and effectively provided and all other coverage criteria are met.
This is good news for those who have chronic or progressive conditions, such as ALS, MS, and Parkinson’s Disease, where improvement may not be possible, but skilled care is needed for services to be safely and effectively provided.
It’s so important for you to know your rights, and to have an insurance agent that you can depend on to advocate for your rights when you need it!
Learn more about Jimmo v. Sebelius:
If you have questions about Medicare or other life & health insurance products, click here to contact Linda Bell, a licensed independent insurance broker at Heart to Heart Insurance Agency, LLC.
Disclaimer: Heart to Heart Insurance Agency LLC is not connected with or endorsed by the United States Federal Government, Centers for Medicaid and Medicare Services, or the Department of Health and Human Services.