On January 24, 2013, a settlement was reached in a class-action suit called Jimmo v. Sebelius, which was pending in the U.S. District Court for the District of Vermont. As noted in yesterday’s blog, Medicare Part A will pay for up to 100 days of skilled care services in a skilled nursing facility (SNF) following a hospitalization of three days or more, if medically necessary and all criteria are met. Over the last 18 years, I frequently heard from clients — or heard from the SNF’s case manager — that skilled therapy services would be discontinued in less than 100 days because the patient had “plateaued” or “wasn’t making any more progress” or “wasn’t improving any further.” The concept was that even though the patient’s condition required skilled care, it would no longer be provided. The Jimmo plaintiffs alleged that the law was being violated.
The official fact sheet published by the Centers for Medicare Services (CMS) is here: www.cms.gov/medicare/medicare-fee-for-service/Jimmo As described there, “While an expectation of improvement would be a reasonable criterion to consider when evaluating for example, a claim in which the goal of treatment is restoring a prior capability, Medicare policy has long recognized that there may also be specific instances where no improvement is expected but skilled care is, nevertheless, required in order to prevent or slow deterioration and maintain a beneficiary at the maximum practicable level of function.” See 42 CFR 409.32(c). http://www.law.cornell.edu/cfr/text/42/409.32
What’s the bottom line? If you or your loved one are receiving skilled nursing and rehab services post-hospitalization, you need to be talking with the team about both the “rehabilitation standard” and the “skilled nursing standard,” to maximize the benefits that can be received within the SNF setting.
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