An Update on an Important Medicare Decision

                In 2013 I wrote on this blog about an important court decision that impacted many seniors discharged from hospitals to subacute facilities for rehabilitation.  (See my posts on March 25 and April 1, 2013.)  Up to 100 days of rehabilitative services are covered by Medicare but many seniors receive well short of 100 days of coverage because of a misapplied standard.  The decision to stop Medicare coverage has been based on a determination that the senior is not improving as a result of the treatment received, despite the fact that nowhere is this actually written in the Medicare regulations.

                Medicare advocacy organizations filed a lawsuit to stop the practice.  A settlement was reached in the case of Jimmo v. Sebelius in which the federal government agreed to stop applying an “Improvement Standard”.  Federal officials agreed to rewrite Medicare manuals to insure that this standard would no longer be used.  4 years later, however, the federal government hasn’t complied so the advocacy groups went back to court.  In February, the Jimmo court approved a corrective statement which the Center for Medicare and Medicaid Services (CMS) must now use to disavow the “Improvement Standard”.

                The statement is intended to remind the Medicare community that Medicare covers rehabilitation when a beneficiary needs skilled care in order to maintain function or to prevent or slow down the patient’s decline or deterioration.  This is what is termed a “Maintenance Coverage Standard”.   To be a clear, showing improvement is not the standard.  A failure to show improvement, by itself, should not cause Medicare coverage to stop.

                This issue affects many seniors who are frail and for whom rehabilitation may not improve their conditions.  The Jimmo case was intended to make it clear that Medicare will cover skilled therapy and nursing services that are needed to maintain a person’s current condition or slow down further deterioration.  Under the terms of the court’s order, CS must provide additional training for Medicare contractors.  If you or a loved one is faced with a termination of Medicare coverage be sure to inquire as to the circumstances of that determination so that the correct standard is being applied.

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