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A loved one is brought from the hospital to a rehabilitation facility to receive nursing care and physical therapy treatment. Medicare is covering this cost. After a month of being provided with such care, the facility tells the family that their loved one is going to be denied Medicare coverage going forward because his condition is “no longer improving.” The family is faced with paying the private pay rate of a nursing home to the tune of $350.00 per day, or taking their loved one home when they are not ready because they cannot afford to pay this astronomical cost. Does this situation sound familiar to you?
There has been a recent trend amount nursing and rehabilitation facilities and agencies to deny Medicare services to patients because their conditions had not been “improving” during rehabilitative services. This “improvement standard” of assessing whether or not a patient should receive 100 days of Medicare has never been supported by Medicare regulations, and recently, the standard was successfully challenged in federal court.
What is being done to stop the practice of wrongfully denying Medicare coverage?
There is good news for Medicare beneficiaries who are wrongfully denied the full 100 days of Medicare coverage they are entitled to by the nursing or rehabilitation facility they are receiving care from. A recent court decision Jimmo v Sebelius helps to ensure that Medicare coverage is available for skilled services to maintain an individual’s condition, regardless of whether the condition improves.
In Jimmo v. Sebelius, the lead Plaintiff, Glenda Jimmo, was denied Medicare coverage for home health aides before her 100 days of Medicare were up due to her condition being “unlikely to improve.” The Court held that this “improvement standard” was improper, and that facilities or agencies must instead base Medicare eligibility decisions on whether a person demonstrates a reasonable and necessary need for a skilled care to maintain a beneficiary’s condition or to slow its decline.
What Medicare programs does Jimmo v. Sebelius apply to?
The standard of Medicare facilities must use, as directed by the Court, applies to both Medicare Advantage as well as the traditional Medicare program.
What Medicare services does Jimmo v. Sebelius apply to?
It applies to any beneficiary who requires skilled services to maintain one’s condition or prevent or slow its deterioration regardless of the underlying illness, disability or injury; Further, it applies to skilled maintenance services provided in all three care settings under Medicare Home Health, outpatient therapy and skilled nursing facility benefits.
What if my Medicare coverage was denied years ago? Is coverage under Jimmo v. Sebelius retroactive?
Medicare denials under these circumstances can be reviewed from January 18, 2011 going forward. The Jimmo settlement also establishes a process of "re-review" for Medicare beneficiaries who received a denial of skilled nursing facility care, home health care, or out-patient therapy services.
If you or loved one have been denied Medicare services because of a medical condition that has not “improved,” call Stefans Law Group, PC at 516-692-2744 and speak to one of our attorneys for legal assistance and professional guidance on your rights, and obtaining Medicare and Medicaid benefits you may be entitled to.