Your Medicare Coverage Rights Explained
By Shannon Miller
While you have never heard of The Jimmo v. Sebelius case, it may have significant impact on the cost of your post-hospital rehabilitation care. Here is a summary of the case and how it applies to you and how to obtain your full Medicare benefits.
In the case of Jimmo v. Sebelius, the Center for Medicare Advocacy (CMA) alleged that Medicare claims involving skilled care were being inappropriately denied by rehabilitation facilities based on an “Improvement Standard”—under which a claim would be denied due to a beneficiary’s lack of restoration potential, even though the beneficiary did in fact require a covered level of skilled care in order to prevent or slow further deterioration in his or her clinical condition.
While an expectation of improvement is not unreasonable in some cases, Medicare policy has long recognized that there may also be specific instances where no improvement is expected but skilled care is, nevertheless, required in order to prevent or slow deterioration and maintain a maximum practicable level of function. In fact, the level of care criteria for coverage specify that the “. . . restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.”
You need to be an educated consumer as it relates to these new developments in Medicare coverage. In order to do so, you need to understand the economics of Medicare coverage, and assert your rights to coverage. Most rehabilitation facilities are attempting to maximize their profits, and they do so by sometimes, discharging patients, like you, before the Jimmo standard allows. Know your rights!
For example, hospitals often own rehabilitation facilities and refer only to these facilities without consideration of the best placement for you. Please consider all options for rehabilitation facilities, and like any good consumer, read the reviews! Look at the AHCA website to see if the facility has had any founded complaints against them. Carefully use a referral service for placement, keeping in mind that they earn their fees from the facility. It is better to use a placement service that is paid by you to make the referral. These services often know where beds are available and which facilities have good customer satisfaction. Call our office for a few options locally in this regard.
Often times, Rehabilitation facilities want patients who give them highest reimbursement from Medicare, typically those just discharged from hospital and in their first 20 days of rehabilitative care. These facilities will often attempt to discharge patients after that first 20 days using the “not improving” standard rather than the Jimmo standard “not getting worse”. This means they may attempt to discharge you before you are ready. Assert yourself or contact our office to assist with this issue! Although Medicare pays 100% for the first 20 days only, you are covered for up to 100 days at lower coverage levels, and your supplemental insurance may pay the difference.
Details of Medicare Coverage
If your hospital stay is 72 hours or longer this means you were admitted for 72 hours–sometimes, hospitals will keep you in the hospital on “observation” status. Be sure you are actually admitted, or you may not receive the Medicare coverage on discharge you are entitled to!
Your Medicare benefits entitle you to receive the following reimbursement for 100 days of rehabilitative care per year:
- 100% reimbursement for the first 20 days.
- 60-80% reimbursement for the next 80 days.
The Jimmo v Sebelius case provides that you cannot be discharged as long as treatment is preventing you from getting worse as documented by a doctor assessment up to 100 days.
We often see cases of improper early discharge.
A Medicare Case Resolved
One recent case involved Jane (not her real name) who is in her early 70’s and lives on a lake in a house built on stilts. When she fell and broke her hip, she entered a rehabilitation facility post surgery to complete her treatment. After only 15 days, Jane’s sister who is also her health care surrogate and agent under power of attorney was informed that Jane would be released in a few days.
Although Jane wanted to return home, she was unable to climb the steep stairs without additional rehabilitation. Although her improvement was limited, she needed to continue the therapy and have sufficient time for her bone to heal before attempting to return home. She fit squarely in the category of Not Improving, but needing therapy so as not to decline. The dilemma prompted Jane and her sister to contact our office.
I wrote a letter to the facility administration detailing the Jimmo case, providing the order attached to the case itself. I then went to the facility to speak with the administration and discuss the issues with all involved. After careful review the facility agreed that coverage should be extended for the full 100 days, and after obtaining the rest and recovery time Jane needed, she was able to fully heal sufficiently to climb those stairs! Mission accomplished!
Be An Educated Consumer
You and loved ones can find good facilities. Take these four actions when researching care facilities on your own: rehabilitation, assisted living, independent living, or a skilled care facility.
- Go unannounced the first time you visit. Go on a weekend, when the facility is the lowest staffed when you will see facility at its worst. Are the patients and residents taken care of? Are call buttons going unanswered? Does someone greet you and have you sign in? Is someone watching the door? Go into the hallway and take a deep breath through your nose—this is a good indicator of the quality of facility staff attention to patients and care.
- Greet the residents and talk to them about how they like it.
- Come back and take a pre-arranged tour. Ask them if you can eat a meal. How’s the food?
- Evaluate the friendliness of staff. Is there good eye contact? Are they engaging? Are they willing to assist you with your request to observe different areas of the facility?
Like most of us in the elder community, my first choice for skilled nursing facilities is The Ayres in Trenton, Florida. Residents happily engaged in activities, there is no smell, and the food tastes good.
Your Medicare Resource
Sometimes it’s difficult to keep up with changes in laws that may impact you. We have helped thousands of seniors over the years receive benefits due to them. We can help you and your family with issues involving not only Medicare and Medicaid, but also estate planning, exploitation, probate, and guardianship.