A settlement of a federal lawsuit in Jimmo v Sebelius will increase the amount of days of care for which an older person could expect to receive Medicare payment for therapy provided in a skilled nursing facility. Maintenance therapy is allowed as a service Medicare will pay for in nursing homes. This means that many older persons who have been discharged from a hospital to a nursing home should expect to get more days of Medicare coverage than before this clarification was made. Typically a minimum of 20 and a maximum of 100 days of Medicare coverage in a nursing home are available.
According to statements by the U.S. Health and Human Services Secretary Kathleen Sebelius at the time of last year’s Jimmo settlement, improvement during therapy has never been necessary to receive Medicare payment for therapy. On Dec. 13, CMS published revisions to the Medicare Benefit Policy Manual clearly stating such, which became effective Jan. 7.
The CMS written standards now clarify that maintenance, not improvement, can be enough to justify Medicare payment. Section 20.1.2 of the CMS manual now states: “Coverage of skilled nursing care or therapy to perform a maintenance program does not turn on the presence or absence of a patient’s potential for improvement from the nursing care or therapy, but rather on the patient’s need for skilled care.”
CMS has basic requirements for getting Medicare in a nursing home, beginning with the need for a doctor’s order and facility’s certification. The patient generally must be admitted to the nursing home within 30 days, following having spent three midnights being admitted in a hospital.
Because Medicare payment for the provided care has been denied by insurance companies, nursing homes have been reluctant to continue providing therapy with no assurance of payment being available for services. The insurance companies are the true villains because of their ongoing denial of Medicare coverage for claims that Sebelius said should have been covered according to federal policy. Families who advocate for the care of their family members need to have higher expectations and be prepared to use the new language of the CMS policy manual to appeal therapy claims that seem to have been wrongfully denied.