Historically well informed Elder Law advocates have challenged the denial of Medicare coverage for a full 100 days in skilled care after a three night hospital stay under the premise that this common practice is not consistent with federal law. Finally this denial of coverage may end thanks to a landmark class action settlement.
Those receiving rehabilitation in skilled care or Medicare home care have historically been told that coverage will end when the patient is no longer showing signs of improvement. However, neither Medicare law nor any Medicare regulations require the patient show a likelihood of improvement. But this became “the” accepted practice due to provisions of the Medicare manual and guidelines use by Medicare contractors which suggested that coverage should be denied or terminated when a patient reaches a plateau or is not improving or is stable.
This settlement should result in increased Medicare coverage for rehabilitation in skilled care and home care if the services are needed to “maintain the patient’s current condition or prevent or slow further deterioration.”
Under a proposed settlement expected to be approved by a Federal Judge this week, Federal officials will rewrite the Medicare manual to make it clear that Medicare coverage of nursing and therapy services does not turn on the presence or absence of an individual’s potential for improvement but is based on the patient’s need for care.
While this may increase the Medicare budget it is an honest reflection of what the law is currently. Is it an honest correction of a misapplication of regulations interpreting the law.
Many beneficiaries may now be able to continue Medicare home care and thereby avoid skilled care. In these cases, Medicare costs may actually be reduced by keeping the patient at home. Many more patients should be able to receive the full 100 days of skilled nursing services, so long as the care is required to maintain the patient’s current condition.
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