The Farr Law Firm assists our Level 4 clients with first-level Medicare Appeals via telephone when a nursing home is threatening our client with discontinuation of needed Medicare benefits. The nursing home patient must have been admitted for at least three days in the hospital (note that “observation status” does not count toward those three days), and the nursing home stay must commence within 30 days of the hospital discharge.
Please note that Medicare does not pay for nursing home long-term care if that’s the only service needed in a nursing home. See http://www.medicare.gov/coverage/long-term-care.html which says that “Medicare doesn’t cover long-term care (also called custodial care), if that’s the only care you need. Most nursing home care is custodial care.”
Medicare does, however, pay for short-term therapy and skilled care in a nursing home for up to 100 days. Skilled care includes physical therapy, occupational therapy, speech therapy, wound therapy, and observation of changing conditions. Medicare will also pay for physician-authorized skilled care provided to a home-bound beneficiary on a short-term intermittent basis.
Despite decades of nursing homes and Medicare representatives saying that Medicare stops paying when the patient is no longer improving, there is in actuality no Medicare “improvement” standard, and this was determined in a lawsuit against CMS (the Centers for Medicare & Medicaid Services). The Jimmo v. Sebelius Settlement Agreement – Program Manual Clarifications (Fact Sheet) — containing the rules that the nursing homes are supposed to follow — can be found here. CMS also has a web page summarizing the Jimmo settlement and links to related documents on the issue of skilled care/therapy coverage: https://www.cms.gov/Center/Special-Topic/Jimmo-Center.html
Please see our following article: Important Medicare Change: Patients No Longer Need to Show Progress to Receive Nursing Coverage.
To appeal what you believe is an improper Medicare termination in a nursing home, please download one of these self-help packets:
MEDICARE HOME HEALTH SELF HELP PACKET
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