The Center for Medicare Advocacy recently announced that the Medicare Policy Manuals have been revised pursuant to a recent case known as Jimmo vs. Sebelius. If you have ever had a loved one in rehab covered by Medicare, you may have been told that your loved one was being released because he or she has “plateaued”. The Jimmo case ended the practice of denying Medicare coverage to people who have “plateaued,” or were “not likely to improve.” The Manual revisions clarify that improvement is not required to obtain Medicare coverage.
CMS stated in the Transmittal announcing the Manual revisions:
“No ‘Improvement Standard’ is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). The Medicare statute and regulations have never supported the imposition of an “Improvement Standard” rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly.”
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Glenn Matecun is a Michigan elder law and estate planning attorney. If you have questions about a loved one in a nursing home, he offers a free consultation to discuss your specific situation.