Todd W. Sivia
Attorney at Law
The Center for Medicare Services (CMS) revised certain regulations that will now make it easier for chronically ill individuals to receive Medicare coverage for home heath care, skilled nursing home stays and outpatient therapies. Previously, CMS required individual to demonstrate a likelihood of medical or functional improvement before approving Medicare funds for skilled nursing care and therapy services. Under the “improvement standard,” individuals whose condition stopped improving were denied therapy that might be necessary for them to maintain their current level of functioning. But with the new revision, however, Medicare will pay for such skilled services if they are needed “to maintain the patient’s current condition or prevent or slow further deterioration”—even if the patient’s condition is not expected to improve.
This policy revision has significant financial and planning implications. Most importantly, this means that Medicare may also cover related services—including the cost of room and board in a nursing home. Upon meeting certain conditions, Medicare will pay for up to 100 days of nursing home care.
Under the “improvement standard,” Medicare often only paid for nursing home care for those who qualified an average of 25 to 30 days. Now if you have a loved admitted to a nursing home on “Medicare days,” and you are told that Medicare coverage is ending because he or she is no longer showing improvement and you must begin private pay, you should claim that the wrong standard is being applied. You can file a Medicare appeal so that your loved one continues to receive necessary therapy in order to maintain his or her current condition or to prevent further deterioration.
Similarly, if you are trying to keep a loved one at home for as long as possible before a transition to nursing home care becomes necessary, making sure that the correct standard is being applied could extend the time when your loved one can stay at home. This additional time may afford you enough time to select the best facility for your loved one, or give you extra time if your loved one is on a waiting list.
The new standard also has important beneficial implications for Medicaid eligibility planning. It takes time to complete the final stages of planning necessary toward establishing eligibility, followed by the filing of a Medicaid application. The extra days of coverage means that Medicare, rather than you or your loved one, may pay for nursing home care while the process is finalized. The financial benefit of additional Medicare coverage alone can save your loved one more than the cost of the legal help needed to effectively and efficiently plan for long-term care.
Sivia Legal Insights 