Medicare Settlement - Medicare to Pay for Care in Skilled Nursing Facilities, Even If No Improvement Likely

Wednesday, October 24, 2012

    In a story reported on October 23, 2012, by the New York Times, it was announced that a court settlement has been reached (pending approval of the judge).

    This settlement will result in a very important change to how Medicare policy is implemented in the real world.

    Formerly, although not required by statute, there was a de-facto policy that in order to qualify for Medicare (as opposed to Medicaid) coverage in a skilled nursing facility, you had to be making improvement.

    Medicare (as opposed to Medicaid) authorizes payment for a stay of up to 100 days in a skilled nursing facility if medically necessary, provided a patient has been in hospital for three or more days, for something other than observation.  (This is a bit simplified, but this basically sets forth how the system works).

    Medicare pays for the full cost of the skilled nursing facility for the first 20 days of such care.  Medicare supplemental insurers have to pay a co-insurance payment for days 20 through 100.  Since this co-pay is now $144.50 per day, this totals $11,560 for the full period.

    Many people were denied further Medicare coverage beginning at about day 20, based on the former standard (which is not set forth in law), that a patient needed to be improving in order to continue to qualify for this Medicare benefit of up to 100 days in a skilled nursing facility.  If this improvement could not be documented (or was not documented) people who needed skilled care were routinely moved from Medicare to private pay status, and incurred costs of several hundred dollars per day for their care.

    In a recent settlement with the federal government, the government agreed to change their manuals to clearly state that Medicare coverage of nursing and therapy services “does not turn on the presence or absence of an individual’s potential for improvement,” but is, instead, available to qualified individuals who actually need skilled care.  This is true even if this skilled care is not likely to result in an improvement of the individual’s condition, if the care is needed to maintain the individual’s condition, or to slow further deterioration.

    Medicare coverage of skilled nursing care is still subject to many limits.  There must be a need for skilled care, as opposed to mere custodial care.  Medicare coverage is also limited to 100 days, and is only available after a qualifying hospital stay.
    Still, this very important settlement with the government will allow a great many people the time they need in a skilled nursing facility to properly recover, and to receive the rehabilitation services they need, so that they can complete their recovery, learn to cope with new situations, and then return home, where they may live independently for years to come.