Skilled Nursing Home Care Expanded

What Does Medicare Cover For Nursing and Therapy Services at Home?

“On this, I’ve heard from members complaining because Medicare refused to cover the cost of skilled nursing and therapy care that they were receiving at home,” reports Stillman. “That’s because Medicare had what they called the ‘Improvement Standard.’

“Under this rule of thumb, the member had to show Medicare that the skilled home care or therapy would improve their condition. For those with a chronic debilitating illness, it could be impossible to demonstrate that their care could lead to long-term improvement, even if they required the care to prevent or slow the deterioration of their condition.

“Consequently, Medicare would deny coverage for the care. And the member, needing the care, would have to pay the total cost or otherwise face the prospect that their condition would get progressively worse.”

But the cost of the care could be financially devastating over time. Fortunately there is a significant change in Medicare’s coverage for skilled home care and therapy that our members should be aware of.”

Under the new federal policy, the Medicare retiree is not required to show that the skilled care or therapy at home will improve their condition. Instead they must demonstrate a need for the care, along with the underlying reasonableness and necessity of the services themselves.

“Now we have what is called a Maintenance Standard, in place of the Improvement Standard,” continues Stillman. “In other words, the threshold question is whether  one needs the care in order to prevent or slow a decline in their condition.  And if so, then Medicare should cover the care.

It should be noted this Medicare change was not simply the culmination of a federal review and finding that the Maintenance Standard was a more appropriate rule to follow. Rather, the federal government was sued over its longstanding adherence to the Improvement Standard.

As a result of the lawsuit, Medicare agreed to expand its coverage for skilled home care. “We applaud those who challenged Medicare’s rule that unfairly penalized retirees who truly needed the care to prevent their debilitating condition from getting even worse and possibly ending up in the hospital,” Stillman adds.

“If you are denied coverage for skilled home care by Medicare, you may want to consider appealing the government’s decision, particularly in light of the expanded coverage. As always, you can call or email me for help.”