Every day, families of nursing home patients are told that Medicare coverage will be ending in a day or two, because the patient is no longer “improving.”  Well, that has never been what the Medicare regulations say, but somehow, that has become the common practice across the country.

The good folks at the Medicare Advocacy Project brought these infractions to court and won.  A federal judge in Vermont, whose order applies to the whole country, clarifies that nursing homes can no longer cut off Medicare just because a patient has “plateaued.”

Instead, the (old) new law is: so long as the patient needs skilled care, whether to improve, maintain her condition, or prevent or slow deterioration of her condition, she is entitled to Medicare payment for up to 100 days.  Period.  Looked at another way, if the patient needs skilled care on a daily basis, or if she needs physical, occupational, or speech therapy five days per week, then she is entitled to Medicare coverage for the full 100 days.

The doctor is the most important person for you to work with.  If she agrees that the patient needs daily skilled care or therapies, then a written statement from her will help you win the full 100 days of Medicare coverage.

See here for a further understanding of the end of the “improvement standard,” and then review the self-help packets.  These are straight-forward, easy to read packets that will help you explain to the nursing home administrator that the rules have changed (many of them haven’t heard yet), so that she will feel comfortable submitting the claim to Medicare and continuing the patient’s coverage.

P.S. These rules also apply to home care and outpatient therapy, as well.

Thank you, Medicare Advocacy Project!