Major Settlement Could Have Significant Impacts on Medicare Coverage for Home Health Skilled Nursing and Rehabilitation

As outlined in a Reuters column, the U.S. Department of Health and Human Services recently settled a class action lawsuit regarding Medicare’s coverage (and denial of coverage) for rehabilitative and skilled nursing services.  Medicare typically denied coverage for skilled nursing and rehabilitation, as covered under Medicare Part A, when a patient did not demonstrate an ability to improve.  This class action lawsuit included patients who need skilled nursing and rehabilitation services to manage their conditions or maintain their current health.

While this is a significant change, it does not fundamentally alter most of Medicare’s stringent criteria for skilled nursing care to be covered under Part A.  Medicare’s coverage will not extend to “custodial” or day-to-day/long term care that many seniors need to maintain independence and health at home and/or in their current level of functioning.  If you are not sure about Medicare’s coverage of skilled nursing and home health care or what makes up skilled versus “custodial care”, EasyLiving offers a great guide to help you easily understand the parameters and understand payment/benefits options for all care:

This lawsuit, Jimmo v. Sebelius, provides that Medicare will relax the requirements for skilled nursing and therapy services (both home health care and those provided in an inpatient setting like a skilled nursing facility) as related to improvement.  There must be a demonstrated need for skilled care and the patient must meet all of the other criteria (such as a qualifying hospital stay for inpatient therapy and being homebound for home health care, along with doctor’s orders and treatment plan for the care).  This could have significant impacts, however, especially on patients who have chronic conditions and rely on occasional skilled care and therapy to maintain functioning and health.

The court is still working on final approval of the settlement and then Medicare will have a time period to implement and educate about the changes.  In the meantime, a number of Medicare beneficiaries who were denied benefits for skilled services (before January 18, 2011 when the lawsuit was filed) will have their claims re-examined.  This is such recent news, with the details still being settled, that it may not filter down to healthcare providers and patients for some time.  It is an important advocacy issue to be aware of and seek help if you (or a loved one) feel you are being denied services under these new standards.

The Medicare Rights Center offers free counseling by phone at 1-800-333-4114 if you have questions or concerns.  To better navigate Medicare coverage and maximize benefits, you should also consider the value of an independent patient advocate such as our Aging Wisely care managers.

Understanding how to access home health agencies’ services and in-home care support can be complex.  Our Senior Care Consultant, Sue Talbott, is here to help you through those questions to ensure you access the care you need.

EasyLiving provides what is often termed “private duty” home health care, services which are not covered under Medicare Part A, but are essential for health and well-being for many seniors.  Skilled care as covered by Medicare can be thought of much like any acute healthcare used by individuals of any age–it is intended to identify and treat acute problems (or the acute issues of chronic conditions).  Private duty home healthcare services are the essential partner to such acute care treatment–the day-to-day things that support health.

Medicare home health agencies and a variety of medical providers work closely with our team at EasyLiving because they know this support is vital to a patient’s success.  For example, nutrition and meal preparation services help patients maintain the proper diet for their condition and strength needed to heal.  Transportation services enable patients to get to follow-up appointments or maintain social connections which have been proven to have a major positive effect on health.  And, home care support can reduce the chances or repercussions of falls, which have devastating outcomes for elders.

Want to know more about how we can help support someone you care about at home?  Call us at 727-447-5845!