Medicare “Improvement Standard” Education Campaign to Finally be Implemented
As Aging Life Care™Managers, we often assist our clients who have been hospitalized to find the best skilled nursing facility for rehab services before going back home. Under Medicare regulations, patients are entitled to up to 100 days of rehabilitation in a skilled nursing facility following a three day hospital stay. Many seniors are under the misconception that they are guaranteed to get a full 100 days of rehab in a skilled nursing facility, but this is often not the case. They are surprised when they receive a notice that they are “ready for discharge” after only two or three weeks. Often, the facility will use language stating that the patient has “plateaued” or “will no longer improve” from skilled services as the rationale for discharge.
In January, 2013, the United States District Court for the District of Vermont approved a Settlement Agreement in the matter of Jimmo vs. Sibelius. This case alleged that an “Improvement Standard”, unsupported in Medicare regulations, was being applied to determine the length of coverage of rehabilitation services based on the patient’s lack of potential of functional improvement. This case and Agreement upheld that there was no indication in the Medicare regulations that improvement or potential for improvement should be applied in determining coverage for rehabilitation services. From the Settlement Agreement, “A beneficiary’s lack of restoration potential cannot, in itself, serve as the basis for denying coverage, without regard to an individualized assessment of the beneficiary’s medical condition and the reasonableness and necessity of the treatment, care, or services in question. Conversely, coverage in this context would not be available in a situation where the beneficiary’s care needs can be addressed safely and effectively through the use of nonskilled personnel. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves.” https://www.cms.gov/medicare/medicare-fee-for-service-payment/SNFPPS/downloads/jimmo-factsheet.pdf
As care managers, we followed this ruling closely, and we were shocked to find out that, in practice, very few facilities were complying with this ruling. When we asked providers about the change, they were either unaware of the change, or willfully continuing to use thenon-existent “Improvement Standard” to base their determination of length of rehab services.
In August, 2016, The Federal judge overseeing the Settlement Agreement in the case, now named Jimmo vs. Burwell, ordered the Secretary of Health and Human Services to submit a Corrective Action Plan to address the inadequate implementation of the Settlement Agreement terms, specifically the Education Campaign. On February 2, 2017, she ruled on the content of the Corrective Action Plan. “The Corrective Action Plan will include a new CMS webpage dedicated to Jimmo, a published Corrective Statement disavowing the improvement standard, a posting of Frequently Asked Questions (FAQs), and new training for contractors making coverage decisions. In addition, and significantly, the Court largely adopted the Corrective Statement drafted by plaintiffs, and ordered the Secretary to conduct a new National Call to explain the correct policy.” This campaign is to be completed by September 4, 2017. http://www.medicareadvocacy.org/medicare-info/improvement-standard/
As Aging Life Care Managers, we were pleased to see this corrective action ordered, and look forward to seeing our clients get their full Medicare benefits in a rehab facility. However, we do not assume that all facilities will readily implement this change. Aging Life Care Managers can be an important partner and advocate for elders and their families in many situations, but we are particularly effective in advocating for our clients when their rightsmay not be fully respected. A professional, objective, experienced voice can be important for the client when they may also be dealing with illness, disability, pain, and concern for their future. A care manager can also provide guidance through the spectrum of care, including rehabilitation services, medical care, housing, and community care options. We providerecommendations for appropriate levels of care, connections to quality providers, and a strong voice of advocacy when needed! We are also involved locally, regionally and nationally in policy advocacy through our National professional organization, the Aging Life Care Association. Please visit our websites at www.lcadvocates.com and www.aginglifecare.org/ to learn more!