Medicare coverage is still being denied for “failure to improve” and that’s against the law.[1]
In the year 2000, my Cousin Kathie at age 93 had pneumonia, ended up in the hospital for 4 days and then discharged back to her nursing home facility. She had dementia. There was no way Kathie could follow instructions to regain her strength. Medicare denied her coverage to pay for her rehabilitation because they said she was not improving. That was the law then.
The Medicare program was sued for taking the position that benefits are only available to those who improve. Medicare lost the lawsuit. Since 2013 Medicare must cover skilled care and therapy when they are “necessary to maintain the patient’s current condition or prevent or slow further deterioration.”
If the new version was available in 2000, my Cousin Kathie would have received therapy to slow down her deterioration and perhaps she would have had greater personal and physical independence.
Why is there a problem? The old law was in effect for over 30 years, and the service providers have been slow to adopt the new law, resulting in a denial of benefits to people like Cousin Kathie. What can you do? If this happens to you, an appeal must generally be filed within in 72 hours of the denial of benefits. If families fail to pay attention, they may end up paying thousands of dollars out of pocket for what should have been provided by Medicare.
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[1] “Failure to Improve is Still Being Used, Wrongly, to Deny Medicare Coverage”, Paula Span, The New York Times, September 12, 2016
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