Skilled Maintenance Services Covered Under Medicare

 

As I still see skilled nursing facilities and home health agencies applying the “improvement” standard for continued Medicare coverage for skilled care and rehabilitation, I thought it might be helpful to again highlight the determination this past January of the national class action suit, Jimmo v Sebelius, No. 11-cv-17 (D.VT). Hopefully this information can be a useful tool for advocacy.

The improvement standard is a deeply ingrained rule of thumb used to justify termination or denial of Medicare coverage for medically necessary skilled care to beneficiaries who are “stable,” “chronic,” “not improving,” or for whom necessary services are for “maintenance only.” The term often used is the patient has “plateaued.” This despite the fact that Jimmo v Sebelius determined that “the Medicare Act and federal regulations support coverage for skilled maintenance health care and therapy. . . . [E]ven if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities. . . .” 42 CFr §409.32(c).

We have one such client who suffers from a degenerative neurological disease that has impacted her ability to walk and transfer from her wheelchair. Home health has been coming out for periods of time over the last year. The therapy has been extremely beneficial in improving our client’s strength and maintaining her ability to make transfers safely in and out of her wheelchair. Unfortunately, when the physical therapist can no longer document “improvement” she is discharged from service. Because her disease is degenerative, she naturally begins to lose her strength and endurance once therapy is discontinued, and she becomes a fall risk with transfers. Were home health to remain consistently working with her, helping her maintain the gains she makes during therapy, she could delay the deterioration from her disease process, remain independent in some of her care and remain safe from falls. According to this agreement, she is entitled to that care under Medicare regulations.

Part of our life care planning approach to elder care law includes advocacy with medical providers to help ensure our clients receive the benefits and care to which they are entitled.

 

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