The Jimmo Settlement clarified that Medicare coverage is based on a patient’s need for skilled care, not on the ability to improve. This means that patients in rehab or skilled nursing facilities cannot be denied services solely because they are no longer making measurable progress. Care must be provided to maintain condition or prevent deterioration.
What to do if asked to leave:
Reference the Jimmo Settlement to remind staff that Medicare does not require improvement for continued coverage. File an appeal with Medicare if necessary. Contact a local legal aid or advocacy organization for support.
For more details, visit:
https://www.cms.gov/medicare/settlements/jimmo.
‘If you or a loved one is enrolled in Medicare, it’s important to stay on top of developments. Too often, people enroll and then stop paying attention to the plan they are enrolled in, or just accept whatever they are told their coverage will be during each annual renewal period. That can mean paying more or being denied covered care.
You are not going to just accept that, right?
Okay, here are two important issues you need to be aware of:
Appeal any denials of coverage.
If you are enrolled in a Medicare Advantage plan, you likely need to get pre-authorized approval for plenty of big-ticket care costs. What you need to know is that if your insurer says no to a preauthorization request, it’s not likely a hard no.
A study by the non-partisan Kaiser Family Foundation found that when patients appealed an initial denial, the insurer reversed its decision in more than 80% of the cases, and agreed to cover the cost in whole or in part.
Let me make sure that’s clear: When patients were denied coverage (preauthorization was not granted) but then persevered and filed an appeal, insurers in more than 80% of those appeals basically said, “Oh, okay, we’ll cover it.”
It’s hard not to see this as an attempt by insurers to save money, by starting at “No.” In fact, insurers know that most enrollees don’t appeal: In 2022 just 10 percent of people denied coverage filed an appeal.
If you are a child of a parent or loved one enrolled in a Medicare Advantage plan, I want you to be aware of this. If you hear your loved one was denied coverage, please help them file an appeal. There’s a very good chance the insurer will change its mind and pay for the requested service.
The new cap for Part D drug costs may cause higher premiums.
Beginning in January, there is a $2,000 cap on what an enrollee will be required to cover out of pocket for prescription drug costs. This will represent a big savings for enrollees who are prescribed high-cost medications.
That’s great news for enrollees. However, it is expected to cause insurers to increase the monthly premium cost for Part D prescription drug plans, and it could cause insurers to change their rules on what drugs they cover.
That’s why anyone with a Part D plan—whether you currently use it to pay for medications or not—needs to be extra sure to pay attention to their 2025 renewal notice that will soon be arriving (if it hasn’t already).
This is not the year to ignore this notice. You need to make sure you know what your premium will be—insurers will release 2025 rates soon—and if you are currently prescribed medications, double-check that they will continue to be covered by your current plan at an affordable rate. From October 15 to December 7, you can make changes to your Medicare plans, including Part D coverage.
Shopping around for the most cost-effective Part D coverage makes a ton of sense. Just be sure to consider both the monthly premium and any copays for a given drug you currently use. And of course, confirm that the plan does indeed cover the drug. The government’s Medicare Plan Finder will show you plans available in your area. Or if you have a trusted Medicare insurance agent, ask them to help you analyze your options for 2025.”
Medicare Part A provides coverage of up to 100 days of inpatient rehabilitation in a skilled nursing facility (SNF) per benefit period. However, full coverage is limited to the first 20 days. Starting on day 21, patients are responsible for a daily copayment, which is $200 per day in 2024. After 100 days, Medicare coverage for inpatient rehab ends.
For patients who require ongoing therapy to prevent their condition from deteriorating, Medicare Part B can cover outpatient therapy services, such as physical, occupational and speech therapy. These services are typically provided in an outpatient setting rather than a skilled nursing facility.
However, if a doctor examines the patient and determines that continued therapy is necessary after rehab, they can order home health services, including physical therapy. Home health therapy is covered under Medicare Part A or Part B, depending on the specific circumstances. To qualify, a doctor must certify that the patient is homebound and requires intermittent skilled nursing care or therapy. The patient must also receive care from a Medicare certified home health agency. Medicare will then cover necessary services, including physical therapy, without time limits, as long as the patient remains eligible.
This option allows patients to continue receiving the care they need at home, without having to stay in a facility.
Source: 1-800-Medicare
I wonder what this means in terms of length of time covered. As we all know it seldom exceeds 21 days. I wonder what it has to do with any ability to participate in any therapies.
Very interesting. Thank you for posting this. I hope we will get to hear more.