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Medicare Settlement May Affect Many

Mom has dementia, Alzheimer’s, Parkinson’s, Multiple Sclerosis or is in a general declining state of health due to advanced age.  She has an acute condition or injury that requires her entry to the hospital and then to a sub acute facility for rehabilitation.  Up to 100 days of rehabilitative services are covered by Medicare, but well short of that time frame Medicare stops coverage because Mom has plateaued.   Sound familiar?

The decision to stop Medicare coverage is usually based on a determination that Mom’s condition is not improving as a result of the treatment she is receiving.  This is very common with the elderly, whose recuperative abilities are not what they were at a younger age.  They are frail and weak.  The problem, however, is that this standard, applied for many years, is actually not written in the Medicare regulations.

A settlement reached with Medicare in federal court in Vermont in the case of Jimmo v. Sebelius, is intended to correct that standard to what was originally intended.  Medicare will pay for skilled nursing home stays, home health care, and outpatient services under Medicare Part B if those services are needed to maintain the patient’s current condition or prevent or slow further deterioration.  It is not necessary that the patient’s condition be expected to improve.

Federal officials have agreed to rewrite Medicare manuals to clarify that the patient’s potential for improvement as a result of receiving these services is not the determining factor as to whether he/she should be eligible for continued coverage.  This change in practice could affect many elderly and disabled who are suffering from chronic illnesses and injuries.  It also could be financially costly to the government as coverage, no doubt, will be expanded in many cases.

As with any significant change, it is hard to tell exactly what the future landscape will look like.  To a large extent, we’ll have to wait and see.  But, next week we’ll discuss what is likely to change in the immediate future as a result of this landmark settlement.