Medicare May No Longer Use Improvement Standard to Deny Short-Term Skilled Care

Medicare May No Longer Use Improvement Standard to Deny Short-Term Skilled Care

The beginning of open enrollment and intense speculation about the election's impact on Medicare are not the only Medicare-related headlines these days. A new development may greatly help Medicare beneficiaries with chronic conditions who need skilled nursing and rehabilitation.  

In the past, Medicare would continue to cover skilled nursing care and short-term rehabilitation, like physical and speech therapy, only if the patient demonstrated that he had the potential to improve as a result of treatment. Obviously, those with chronic conditions like Alzheimer's Disease, heart disease, Parkinsons, Lou Gehrigs disease, arthritis - in other words, those who could not meet the so-called improvement standard -- were most impacted by this rule. (In fact, the so-called "improvement standard" was technically never a part of Medicare law; it had simply become the de facto standard used by Medicare decision makers.)

Now, a federal court has ruled that the improvement standard cannot be used to deny Medicare coverage for skilled nursing care and rehabilitation. The settlement in the class action lawsuit Jimmo v. Sibelius requires Medicare to cover skilled nursing and therapy even if it just maintains a person's medical condition or prevents further deterioration.  The proposed settlement was reached in federal district court on Oct. 16, 2012.

However, it's critical to note these important caveats: 

  1. The case does not change the maximum number of days of skilled care Medicare covers per benefit period. Medicare will pay 100% for a maximum of 100 days, and only if it follows a hospital stay or stay in a rehab facility.
  2. The case does not impact whatsoever on long-term, custodial nursing care, which is still not covered by Medicare, but may be covered under certain circumstances and with proper planning by Florida Medicaid.

More details here.

Attorney Joseph S. Karp is a Florida Bar Certified and Nationally Certified Elder Law Attorney focusing on Elder Law, Probate, Estate Planning, Asset Protection, Special Needs Planning and Estate Litigation. He is AV rated by Martindale Hubbell. Mr. Karp is the founder of The Karp Law Firm, a South Florida law firm with offices in Palm Beach Gardens, Boynton Beach and St. Lucie, Florida.  Mr. Karp was named a 2011 SuperLawyer by SuperLawyer Magazine and a member of the 2011 Florida Legal Elite by Florida Trend Magazine. He is admitted to practice law in New York as well as Florida. Visit Mr. Karp's Florida Elder Law and Estate Planning website. 

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Comments

Anonymous
Anonymous
  • 11-15-2012

I hope their is huge change in medicare plans for past two years. They increased insurance premium at the same time benefits also increased.