On July 24, 2010, an article entitled “The Dreaded Plateau” appeared in this blog. It explained why some Medicare patients have trouble getting their full 100 days of skilled care or rehabilitation. The recent settlement of a federal class lawsuit addressed the “progress” requirement often incorrectly applied to patients in skilled care. The progress requirement is also referred to as the “improvement standard.”
Medicare covers up to 100 days of skilled care or rehabilitation. Rehabilitation or skilled nursing facilities will issue a Notice of Medicare Skilled Care Termination as soon as there is any doubt that the patient needs skilled care. Often the reason given is that the patient has reached a “plateau” in his or her progress. That requirement is not supported by Medicare law, but it was used by facilities and permitted to be used by the Centers for Medicare and Medicaid Services (CMS), the federal oversight agency for federally-supported health care programs.
The attorneys at the Center for Medicare Advocacy (CMA) are are true heroes in the battle to maintain a reliable, healthy Medicare program and in the struggle to help Medicare members get the best possible care. In conjunction with Vermont Legal Aid and other advocates, CMA achieved a landmark settlement with CMS. In Jimmo v. Sebelius, No. 11-cv-17 (D.Vt.), filed January 18, 2011, a proposed settlement was reached October 16, 2012. When the agreement is signed by the judge, CMS will revise the Medicare Benefit Policy Manual and other Medicare Manuals to correct suggestions that Medicare coverage is dependent on a beneficiary “improving.” New policy provisions will state that skilled nursing and therapy services necessary to maintain a person’s condition can be covered by Medicare. This settlement is described in detail on the CMA website.
John B. Payne, Attorney
Garrison LawHouse, PC
Dearborn, Michigan 313.563.4900
Pittsburgh, Pennsylvania 800.220.7200
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