Medicare Coverage, the Improvement Standard, and the Fight for Continued Coverage in Rehab

So a few years ago, there was a big court case that changed the way Medicare insurers are supposed to evaluate whether they will continue to cover a skilled nursing stay (when you are in there for rehab). It used to be, that coverage would stop when you were no longer improving from rehab. But the court case (called Jimmo v. Sebelius) was settled when the government agreed to change that standard so that Medicare coverage would continue as long as that skilled nursing and therapy are necessary to maintain a person’s condition.

Those of you who have ever been through this experience know that, sometimes when people are that sick, they have no hope of improving beyond a certain level, but the minute you take away therapy, they lose the little they have gained. So this change was definitely a good thing.

Then why am I bothering to write about it? Because even though this settlement took place about 3 years ago and the Medicare manuals were revised 2 years ago, somehow it does not seem to be consistently used. People are still being denied coverage when they stop improving. It might not be stated quite that way anymore, but that is the end result.

So how do you know you’re facing the situation I’m writing about? Well, you could be getting outpatient therapy, home health care, or be inpatient in a skilled nursing facility and your therapy is being covered by Medicare and then you get a notice that your Medicare coverage is ending. Each of these situations has different nuances specific to how you are receiving services, but if any of them are ending because your therapist or doctor believes you will not improve, it’s possible an appeal is order.

  1. First of all, if you think you need continued services, the key is making sure services continue. Because Medicare will pay for services provided but not services that should have been provided. I know this is tough, because if you lose an appeal, you’ve incurred fees that now have to be paid for out of pocket. So how do you make a decision whether an outcome is likely going to come out in your favor?

  2. Get your medical team onboard. The medical opinion is key to continuing coverage. As strange as it may seem, there are still medical professionals out there who don’t know about this change in policy. So talk to the therapists and talk to your doctor. If the doctor affiliated with the services you’re receiving is not helpful, go to your family doctor. If they don’t seem familiar with the maintenance standard, educate them.

  3. The key to this standard is that the person receiving services needs the services when they are necessary to maintain or improve the condition (not when improvement is expected). You may be told you have plateaued, or returned to baseline—that is not a good enough reason to discontinue services.

  4. What does the doctor need to say: if your care is discontinued your health will be placed at significant risk, and why “your health will be jeopardized” (yes, use that exact phrase).

  5. Don’t miss deadlines! The deadlines in your notices are hard and fast. There is no wiggle room. Do not miss them. You can always withdraw an appeal later. You cannot decide to appeal after a deadline has passed.

This is really just a starting point to what is a long and complicated process. But what I want you to take away, is that you do not just have to accept that rehab is ending just because someone tells you Medicare won’t pay for it. If it’s doing good, try to keep it going!