Expansion of Home Care and Skilled Nursing Care under Medicare

posted October 23, 2012

Donald N. Freedman
Susan H. Levin

A new class action lawsuit brought by the Center for Medicare Advocacy has produced a settlement that will enable expanded Medicare coverage of home care services and also skilled nursing and rehabilitation services care in skilled nursing facilities. The settlement applies to all Medicare beneficiaries, both elders younger adults receiving Social Security Disability Insurance benefits.

Medicare pays for home health services for home-bound beneficiaries who need skilled nursing and therapy services. For decades, Medicare approved coverage only if could be proved that skilled care resulted in the medical improvement of the patient’s condition. Services were often discontinued if the individual’s medical or functional condition stopped improving and reached a plateau. This interpretation excluded from coverage many people who were able to show only that the services were needed to maintain the patient’s current condition or prevent or slow further deterioration.

Repeated legal changes to the more restrictive interpretation have finally resulted in the government agreeing to the broader interpretation. It will now be enough to show that services are needed to maintain current condition or slow deterioration. Most affected by the change are likely to be people affected by chronic or degenerative conditions like Alzheimer’s disease, multiple sclerosis, Parkinson’s disease, stroke, spinal cord injuries and traumatic brain injury.

Other criteria must still be met, including that the individual be “homebound.”

The new interpretation also applies to Medicare coverage of skilled nursing facilities. Medicare covers up to 100 days of skilled nursing facility care after a 3-day hospitalization. Lack of progress (“plateau”) has often been used to justify discontinuing coverage well short of the 100 days. Once the settlement is implemented, proof that skilled care is necessary to maintain function or slow deterioration should be sufficient to enable continuing Medicare coverage.

Under the settlement, the government will issue revised standards that will apply to beneficiaries who are currently receiving or may apply for home health benefits in the future. In addition, Medicare beneficiaries whose claims for skilled nursing and therapy services were denied before Jan. 18, 2011, when the lawsuit was filed, will have an opportunity to have their claims re-examined under the revised standards.

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