Back in January 2013 the Centers for Medicare and Medicaid Services (CMS) settled a class action lawsuit called Jimmo v Sebelius concerning premature cutoffs of skilled care benefits under Medicare Part A. The problem was that patients in skilled care facilities after hospitalizations, who were placed there for skilled nursing and rehabilitation, were finding that their benefits were being cut off once they were “no longer progressing” towards the rehabilitation goals. “The patient has plateaued” was a common refrain that families would hear. The rule of thumb was that the patient had to meet the “Improvement Standard.” Yet the Medicare statute authorizes payment for up to 100 days for a patient who requires skilled nursing services or skilled services from licensed personnel such as physical therapists, occupational therapists and speech language pathologists, when necessary to maintain their condition and prevent deterioration, regardless of failure to improve. And in the settlement, CMS agreed to send out clarifying directives to all facilities that participate in the Medicare program.
After two years in which facilities were apparently abiding by the CMS reminders regarding “need for skilled care” as the measure, my clients in “rehab” centers are beginning to report to me that the old “improvement standard” is once again being held out as the measuring rod for continued skilled care. This is evidently happening even for patients whose fragile clinical condition clearly requires the services of licensed nurses to maintain their condition and prevent further deterioration. If you encounter this problem, demand a care plan meeting to be set up. Bring a copy of the JIMMO settlement press release (attached)www.cms.gov/medicare/medicare-fee-for-service/Jimmo and remind the staff that regardless of pressures brought by the patient’s insurance carrier, the law is the law.
For legal advocacy and representation concerning long-term care, skilled care and elder care call 732-382-6070