Within the abundance of information regarding benefits that may or may not be available for patients in a skilled care facility is a mound of confusion and frustration. The Kaiser Family Foundation files share “The recently enacted health reform legislation mandated a number of policy changes, demonstrations, and other initiatives relating to nursing home and hospice care. These provisions demonstrate Congressional recognition that Medicare and Medicaid policies relating to nursing home and hospice care are far from perfect and require modification.” However, knowing requirements, preferences, options and individual facility agreements is a common cause of frustration and difficult to understand. This article shares a basic thought to pursue if your loved one is in a critical state and residing in a skilled nursing facility.
Caregivers: don't let the nursing home business office tell you that Medicare can no longer cover room and board for your loved one because he or she isn't "improving."
The Improvement Standard is not, and never has been, a valid reason for nursing homes to cut off these nursing home days. Medicare's nursing home payment manual makes it clear that "[e]ven in situations where no improvement is expected, skilled care may nevertheless be needed." This manual was published in 2014, but some nursing homes haven't adapted to help chronic patients get access to the coverage they are eligible for. Many business offices rely on software programs to manage their billing, and those programs haven't caught up to the Jimmo v. Sebelius court decree issued on January 24, 2013.
Need for skilled care is the requirement for this coverage of nursing home room and board. "Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities," the manual states.
For example, Medicare will consider a nursing home resident's maintenance therapy program to be a skilled service, if the therapy can be safely and effectively performed only by, or under the supervision of, a qualified therapist.
The Code of Federal Regulations offers this example: "A patient with Parkinson's disease may require the services of a physical therapist to determine the type of exercises that are required to maintain his present level of function." The list and its qualifications is simplified by
- the initial evaluation of the patient's needs,
- the designing of a maintenance program which is appropriate to the capacity and tolerance of the patient and the treatment objectives of the physician, and
- the instruction of the patient or supportive personnel (e.g., aides or nursing personnel) in the carrying out of the program, would constitute skilled physical therapy and must be documented in the medical record."
(Learn more about the Difference Between Skilled Nursing and a Nursing Home.)
Medicare Payments for Home Care
The requirement for skilled services also applies to home care paid by Medicare. The Code of Federal Regulations elaborates on this requirement:
"A patient was hospitalized following a heart attack. Following treatment he returned home. Because it is not known whether increasing exertion will exacerbate the heart disease, skilled observation is reasonable and necessary as mobilization is initiated in the patient's home. The patient's necessity for skilled observation must be documented at each home health visit until the patient's clinical condition and/or treatment regimen has stabilized.
"If the patient's overall condition supports a finding that recovery and safety can be ensured only if the total care is planned, managed, and evaluated by technical or professional personnel, it is appropriate to infer that skilled services are being provided."
Many other services that qualify as skilled nursing services, and skilled rehabilitation, are listed in the Code of Federal Regulations, 42 CFR 409.33 (a) (b) and (c).
Understanding these rules can help you be a better health care advocate, as well as a good money manager who knows when Medicare should continue paying for nursing home room and board.
As always, perform your own thorough due diligence by researching, reading and asking questions so that you and your family can make the best informed decisions for the situations of your loved one. Their manual offers what is perhaps the most solid piece of instruction in its conclusion saying “these cases must be carefully documented.” The bottom line is that vigilance and advocacy by family members will be necessary to protect a loved one’s eligibility for Medicare nursing home coverage.