My first job as a social worker was in skilled nursing facilities, aka nursing homes.  While I loved many aspects of my job, I dreaded the weekly meeting that was held to determine which Medicare patients were making progress from our therapy services, and who was not.  Those who were deemed to be plateauing and no longer benefiting from physical, occupational, speech, respiratory, or nursing skilled therapy services were given a 72 hour written notice from our team that Medicare would no longer be covering their stay in our rehabilitation facility.

For many patients, this meant a scramble to find alternative care settings, or arranging services to be brought into their homes for the transition.  No one was happy to see me walk in the door with that letter.  It meant that Medicare had given up on them, at that particular juncture, with that particular injury.  Some would appeal our decision, but it was rare that the ruling would be in their favor.  The saddest cases were those who had some form of dementia along with their diagnosis that landed them with us (broken hip, stroke, etc…).  These folks simply could not follow the instructions given to them in order to make progress/improvement with their injury.  Typically they were discharged just a week or two after admission, and they were the lucky ones!  They had straight Medicare, not an HMO or they would have been shown the door earlier… But that’s for another post.

So, it is with great pleasure to have learned about a recent ruling that will have an immediate effect on this process.  A federal court settlement in Jimmo v. Sebelius has been approved.  New policy provisions will state that skilled nursing and therapy services necessary to maintain a person’s condition can be covered by Medicare.  This replaces the “improvement standard” that providers have subscribed to for years.  

According to Medicare Advocacy.org “CMS will undertake a comprehensive nationwide Educational Campaign to inform health care providers, Medicare contractors, and Medicare adjudicators  that they should not limit Medicare coverage only to beneficiaries who have the potential for improvement.  Instead, providers, contractors, and adjudicators must recognize “maintenance” coverage and make decisions based on whether a beneficiary needs skilled care that must be performed or supervised by a professional nurse or therapist.”   

To break it down, Medicare recipients can’t be kicked off skilled services (therapy services such as PT, OT, etc…) simply because they aren’t making significant improvement.  In the case of the Medicare recipient with dementia and a fractured hip, he/she will now receive therapy services despite the dementia diagnosis until the hip is treated to maintain his/her current condition and to prevent further decline.

“Lawyers for the beneficiaries say the settlement could help people with chronic conditions like Alzheimer’s, Parkinson’s, multiple sclerosis, strokes, spinal cord injuries and brain trauma. Often the prospects for improvement are slim, but there are ways to slow a patient’s deterioration and help the patient to live long enough to take advantage of new treatments as they are developed.” New York Times

While substantial costs are expected to be added to the Medicare program because of these changes, there may also be savings realized if recipients can receive therapy services in their homes.  The increased therapy should also keep these patients out of more costly settings like hospitals and nursing facilities and keep readmission rates low.

To learn more about the settlement, or if you would like to appeal a past decision made by a Medicare provider, the article from the Center for Medical Advocacy has many helpful links and resources.