THIS IS ANOTHER “Medicare thing.”
If you’re not on Medicare, don’t like anyone who is and don’t plan to get anywhere near it anytime soon, you probably don’t care.
If you are (a) on Medicare or about to be (or, care about someone who is) and (b) not immortal, you could likely care, deeply.
If some of this sounds vaguely familiar, take that as an encouraging sign because I have gone on about it before.
The topic here today is the Jimmo Settlement.
Let’s back up.
Many of us who have been knocking around Medicare since the Pleistocene Era, including medical providers, got this thing in our heads called the “improvement standard.”
It basically said that skilled nursing and skilled therapy services (i.e. physical therapy, speech therapy and occupational therapy) could only continue as long as the patient was “improving.” Once “improvement” stopped, those services stopped because, we thought, Medicare would no longer pay for them.
Wrong.
In fact, one plucky Medicare beneficiary decided it was so wrong that she took the issue to federal court — and won.
The court ruling basically said that a Medicare beneficiary has a right to those services to prevent “decline” and/or to maintain her or his current level of health/functioning.
In other words, you don’t have to be “getting better” to have Medicare pay for these services. You simply have to need them in order to keep from getting worse.
That’s a big deal. And, a big change.
Since the original court decision, there’s been all sorts of legal wrangling about whether or not Center for Medicare and Medicaid Services (CMS) — the agency that runs Medicare — was doing enough to let beneficiaries know about this policy change and to educate providers as to the change in policy.
Basically, the court said they weren’t so, among other things, CMS has developed a website — https://tinyurl.com/PDN-CMS — that goes into this matter at considerable length and detail.
CMS has also revised the Medicare Policy Manuals to clarify the matter for medical providers.
These are hugely voluminous manuals that govern, dictate, clarify and specify what Medicare does/doesn’t do, does/doesn’t pay for, how to do it, etc. ad infinitum.
Here is a paragraph from the “Transmittal” that went out with those policy revisions:
“No ‘Improvement Standard’ is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e. to prevent or slow a decline in condition) … 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.”
I know: Wow, but this actually affects a lot of folks.
What all this comes down to is you don’t have to get worse, simply because you probably won’t get better.
Just maintaining your current status quo is enough.
That’s a big deal.
Where are you likely to encounter this?
Well, maybe from a home health agency, which has been providing skilled nursing services and/or physical, speech or occupational therapy, or from a skilled nursing facility (remember, this is not “long-term care” in a nursing home — this is about temporary admission for skilled services) or even in the context of out-patient therapies.
Let’s stop here.
Our local medical providers have not been withholding these services because they are selfish, evil or stupid.
They’ve thought they were doing the right thing for a very long time.
So, if you or yours encounter “denials” based on the “Improvement Standard,” it is probably out of honest ignorance of the Jimmo Settlement and the accompanying Medicare policy change.
My guess (certainly, my hope) is that if we provided the website noted above, that would be enough to help them understand current policy.
Now, if it isn’t, there is all matter of elaborate appeals material available, but who wants to go through that?
I don’t, you don’t and our medical providers certainly don’t, so let’s just all get on the same page and live happily ever after, OK?
Here’s the most important point for all of us: You do not have to get worse, simply because you probably won’t get better — and Medicare will pay for it.
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Mark Harvey is director of Clallam/Jefferson Senior Information & Assistance, which operates through the Olympic Area Agency on Aging. He is also a member of the Community Advocates for Rural Elders partnership. He can be reached at 360-452-3221 (Port Angeles-Sequim), 360-385-2552 (Jefferson County) or 360-374-9496 (West End), or by emailing harvemb@dshs.wa.gov.
