Lawyer: Does Medicare cover skilled nursing?

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By Nancy Burner, Esq.

Nancy Burner, Esq.

Skilled nursing care is high-level care that can only be provided by trained and licensed professionals, such as registered nurses, licensed vocational nurses, medical directors, and physical, occupational, and speech therapists.

Skilled care is short term and helps people get back on their feet after injury or illness. Skilled nursing facilities are residential centers that provide nursing and rehabilitation services to short- or long-term patients. Examples of services provided in a skilled nursing facility include wound care, medication administration, physical and occupational therapy, and pulmonary rehabilitation.

Typically, patients admitted to skilled nursing facilities are recovering from surgery, injury, or acute illness, but a skilled nursing environment may also be suitable for people with chronic conditions that require monitoring. constant medical. If you or a loved one are interested in using Medicare for skilled nursing, there are specific eligibility requirements set by the federal government:

• Individual has Medicare Part A (hospital insurance) with a valid benefit period. The benefit period will begin on the date of admission to a hospital or qualified nursing facility and will last up to 60 days after the end of the stay.

• The person has an eligible hospital stay. This usually means at least three days of hospitalization in a hospital.

• The physician has recommended skilled nursing care for the individual on a daily basis. Care must be provided by or under the supervision of qualified nurses and therapists and must be related to the condition being treated during the qualifying hospital stay.

• The person is admitted to a Medicare-certified skilled nursing facility. A skilled nursing facility must meet strict criteria to maintain its Medicare certification.

Usually, skilled nursing services covered by Medicare include room charges, provided it is a semi-private or shared room, on-site meals and any nutritional counseling, as well as the cost of drugs, medical supplies, medico-social services, and ambulance transportation. It also covers rehabilitation services needed to recover from illness, such as physiotherapy, respiratory therapy, and speech therapy.

Medicare generally provides coverage for up to 100 days of treatment in a skilled nursing facility. Note that if the patient refuses daily skilled care or therapy recommended by the physician, Medicare coverage may be denied for the remainder of the stay in the skilled nursing facility. Many patients are told that they will not receive the full 100 days of Medicare benefits because they have reached a “plateau” or have not improved. This is known as the standard of improvement and was a “rule of thumb” used to assess Medicare patients.

Enforcement of the Enhancement Standard has resulted in the denial of much needed skilled care to thousands of Medicare patients. Refusals were based on the finding that there was no likelihood of improvement in the patient’s condition. This standard ignored the fact that patients needed skilled care in order to maintain their current state of health and prevent it from deteriorating. More often than not, if the patient did not improve, Medicare coverage was denied. Although this standard was widely used, it was inconsistent with the law and Medicare regulations.

A lawsuit by Medicare beneficiaries and national organizations against the Secretary of Health and Human Services (Jimmo v Sebelius) sought to change that. Plaintiffs argued that although the term “plateau” does not appear in Medicare regulations, it is this term that is often used and invoked to deny coverage. The appropriate standard should be: will the covered services “maintain the current state or prevent or slow further deterioration”, not if the individual shows signs of improvement.

As a result of this litigation and the January 24, 2013 settlement, patients should be able to continue to receive services provided by Medicare, even when improvement in the patient’s condition cannot be documented. However, the old standard continues to be used. Patients and their advocates should educate themselves on the appropriate standard to ensure coverage is not cut prematurely.

Nancy Burner, Esq. is the founder and managing partner of Burner Law Group, PC with offices located in East Setauket, Westhampton Beach, New York and East Hampton.

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