If you are 65 years or older, then you already know that Medicare is primary health insurance for many. Yet, there has been a recent, but long-awaited, development to help protect certain coverages. The Medicare Fact Sheet has been updated to reflect appropriate standards for Medicare rehabilitation and “plateauing” seniors. So what does this mean for you or a loved one who needs skilled care or therapies in a skilled nursing facility or rehab center?
Explaining Medicare Part A
To give some background for the Medicare Fact Sheet, we must understand how Medicare works. Specifically, we look at Medicare Part A. Under Part A, seniors are able to receive medical services at a hospital and are covered during their stay. If the length of their stay in the hospital was longer than 3 days, they receive Medicare coverage for skilled care or rehabilitative therapies of up to 100 days. Under normal circumstances, the individual during their rehabilitation would see gradual improvement over time and be discharged before day 100. When an individual did not gradually improve or even worsened, however, they would instead fall into a “No Improvement Standard”.
What is a No Improvement Standard?
Simply put, a No Improvement Standard is exactly how it sounds: the individual is not improving during their rehabilitation. Labeled “plateauing”, seniors could see some improvement at the beginning of their rehabilitation process but with diminishing results over time. The issue then comes from how Medicare perceived individuals who were not improving. Medicare stated that without improvement, there was no need for them to continue receiving coverage for their care; instead, the ‘additional’ care would be paid out of pocket, which could be thousands of dollars!
The problems did not stop there, though. Medicare would inform medical professionals that if they provided rehabilitative care beyond what Medicare deemed necessary, including No Improvement Standard cases, those medical professionals would be on the hook for paying back what Medicare deemed wasteful. They could even be accused of Medicare fraud!
What was updated to prevent these issues?
In 2013, a federal case known as Jimmo was settled. It stated that the “No Improvement Standard” could not be applied to seniors who had plateaued during their rehabilitation. Medicare never followed through on ensuring Nursing Homes knew the appropriate standard to apply for coverage, resulting in many seniors being kicked off of their coverage when they plateaued. The lawsuit confirmed that if the therapy was necessary to maintain the progress the senior had gotten, it needed to continue regardless of further improvement or plateau. Only recently, Medicare finally updated its fact sheet to apply the appropriate standard. Now, Nursing Homes have direct instruction from the federal government to stop prematurely ceasing necessary rehab on the basis of plateauing.
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