Feb 4, 2014

Medicare Does Not Pay for Long Term (Nursing Home) Care

In home health care, it is anticipated that the patient and/or caregiver(s) will be taught how to perform self-care by the registered nurse.

Let me start out with this fact,


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Now, an important legal decision/clarification had recently been handed down, which is what this article tells you about.
On January 24, 2013, the U.S. District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius, (Sebelius is Secretary of health and Human Services, the federal agency that includes Medicare as one of the programs it is in charge of.) involving skilled care for the inpatient rehabilitation facility, skilled nursing facility, home health, and outpatient therapy benefits.

In the Jimmo case, a federal judge granted final approval stating that claims could not be denied simply because there was no improvement in the patient's condition. This means that (with proper documentation) continual coverage will be based on the patient's need for skilled care to maintain the patient's current condition and not on the patient's improvement.
To clarify further, CMS (the Center for Medicare Services) states in the Transmittal announcing the Jimmo Manual revisions:

How to Get Answers To Your Questions About Alzheimer's and Dementia

Carole Larkin MA, CMC, CAEd, DCP, QDCS, EICS is an expert in Alzheimer’s and related Dementia care. She is a Certified Geriatric Care Manager who specializes in helping families with Alzheimer’s and related dementia issues. Carole can consults with families via telephone nationwide on problems related to dementia. Her company, ThirdAge Services LLC, is located in Dallas, TX.

By Carole Larkin
Alzheimer's Reading Room< No "Improvement Standard" is to be applied in determining Medicare coverage for maintenance claims that require skilled care.

Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition).

The Medicare statute and regulations have never supported the imposition of an "Improvement Standard" rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient's condition.

Thus, such coverage depends not on the beneficiary's restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly.

Now what does this mean for you and me?

It could mean a lot depending on a couple of different circumstances in regard to your care partner.

Your care partner has only a diagnosis of Alzheimer’s or other cognitive disease. They have no other physical ailments that require nursing care. Even if they fall and break a hip, or something similar, this rule DOES NOT apply to them.

Your care partner has a diagnosis of Alzheimer’s or other cognitive disease and another physical ailment that does require skilled nursing care even after rehabilitation for the broken hip or something similar. This rule DOES apply to them.

Skilled nursing care means that a nurse has to administer the treatment for the disease. Some examples of patients who would qualify for skilled nursing care are:
  • Patients who require intravenous and intramuscular injections
  • Patients needing Foley catheter insertions
  • Patients with pre-existing peripheral vascular or circulatory disease (needing observation for complications, pain management, teaching related to skin care, preservation of skin integrity,
  • and prevention of skin breakdown)
  • A patient who requires teaching related to illness or injury until they can demonstrate independence in their care.
  • Patients in need of medication management which also requires a nursing assessment (such as Blood pressures, pulses, respiratory assessment, blood sugars, oxygen saturations), 
  • monitoring of medication changes or physician consults.
The Medicare coverage of the stay in the skilled nursing facility is intended to get the person to the point that he/she can return to a community setting (with or without continued rehab services).

Now, this does not give everyone blanket coverage of 100 days of rehab in a skilled nursing facility.

Rehab in a hospital setting [7 days weekly--intense] is different than rehab in a skilled nursing facility [5 days weekly--less intense] and is different that rehab in a community [in home or out-patient facility] setting [normally 1-3 days weekly].
If after a stay in a skilled nursing facility a person can receive the rehab services needed to continue his/her improvement OR maintain his/her current status in a community based setting, then discharge from the skilled nursing facility is appropriate.

In home health care, it is anticipated that the patient and/or caregiver(s) will be taught how to perform self-care by the registered nurse. Typically this teaching is done over several days/weeks, depending on the complexity of the task and the patient’s condition.

For this reason, agencies can expect to see patients frequently upon admission, and then begin to reduce the number of registered nurse visits when competency in the task is demonstrated and documented.

If the patient’s nursing goals are met (considered to be stable), or teaching can be completed in one visit, the patient is no longer considered “skilled” and no longer considered “qualified” for skilled care.

Medicare Advantage plans must provide all basic Medicare services--the standards that apply for Medicare beneficiaries apply for Medicare Advantage beneficiaries.

My thanks to Linda Desmet of the St. Louis Alzheimer’s Association and Regina Curran, interpreter and guidance counselor for the National Association of Geriatric Managers for their contributions to this article.

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