Aging Options

Medicare beneficiaries still being denied for 'not improving'

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If you’ve recently had a loved one in a nursing home you may have heard someone say that because your loved one is no longer improving, Medicare will no longer pay for their care.  Last year, in a settlement agreement, Jimmo v. Sebelius, the federal government agreed to end its long-standing practice of denying coverage for beneficiaries with chronic conditions and disabilities based on their lack of improvement.  The new rules require Medicare to cover skilled care as long as skilled care continues to be needed even if the beneficiary experiences no improvement or even slow further deterioration but many providers haven’t gotten the message yet.  That’s led to beneficiaries needing to pay for their care or being denied care that they have a legal right to.

The settlement required Medicare to convey the changes to providers but not to beneficiaries.  But, providers often either don’t know about the settlement or don’t know how to proceed with claims under the new rules.  Medicare beneficiaries denied coverage for skilled maintenance care because they are not improving, are encouraged to appeal the decision.  If you encounter obstacles because your provider doesn’t understand the new rules, the settlement also provided a means for review.  You can find help by visiting the Center for Medicare Advocacy’s website.

If you need assistance or would like to discuss these matters, our Geriatric Care Managers can help get things moving in the right direction.

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