Medicare, a health insurance benefit for people 65 and older, has imposed an artificial “improvement” requirement to obtain certain Medicare benefits, including coverage to pay for rehabilitative services after a 3-day hospital stay. On October 16, 2012 the Centers for Medicare and Medicaid Services (CMS) agreed to settle a case, Jimmo v. Sebelius, which removed the “improvement standard” to get Medicare benefits
What does this mean? The current Medicare manuals include a suggestion that Medicare coverage is dependent on a patient “improving.” The new policy provisions will state that skilled nursing and therapy services necessary to maintain a person’s condition can be covered by Medicare.
The “improvement” standard has harmed thousands of older and disabled Medicare beneficiaries who need skilled care to maintain their conditions. The new standard provides medically necessary nursing services or therapy services, or both, to patients who need them to maintain their functioning or prevent or slow their decline. The important point is whether skilled services of a health care professional are needed, NOT whether the Medicare beneficiary will “improve.”
October 24, 2012 editorial, “A Humane Medicare Rule Changes,” The New York Times
“Settlement Reached to End Medicare’s “Improvement Standard”, Center for Medicare Advocacy, Inc.
“Historic Settlement Will End “Improvement Standard” for Medicare Reimbursement of Long-Term Care, “National Academy of Elder Law Attorney Bulletin, October 31, 2012