Last week, Medicare agreed to expand its benefits for some people with chronic disease, including many elderly. This added care, which came in a settlement of a lawsuit brought by a Vermont woman named Glenda Jimmo, the Center for Medicare Advocacy, and others is potentially very important for some Medicare beneficiaries.
But the settlement does not affect long-term care benefits in any way. Medicare did not pay for nursing home care, home health aides, or other long-term care services before this lawsuit, and it will not do so now. Additionally, the case has no impact on Medicaid. The benefits and eligibility rules for Medicaid remain unchanged.
Yes, this agreement will make it easier for some people who are receiving long-term care to also get skilled nursing care or physical therapy, but it will not require Medicare to pay for any long-term services or supports
Still, many people are confused about Medicare benefits for those with chronic disease and are uncertain about the applicability of this case. People are asking whether this settlement means their mom can now get Medicare long-term care benefits. The simple answer is: No.
That is not to say the settlement is not important. For years, many home health agencies and skilled nursing facilities have interpreted Medicare rules to mean the program would not pay for rehab if a patient is not getting better.
Imagine, for example, an 80-year old named Fred suffers a stroke. There has been no question that Medicare could pay for Fred's physical or occupational therapy. However, the rules have been unclear, and many providers have taken the position that Medicare would only pay as long as Fred's condition improves as a result of this skilled care.
The rules were vague, and Medicare has sometimes argued that providers misunderstood them. Still, many service providers, who feared Medicare auditors would demand repayment for ineligible services, were reluctant to provide rehab or skilled nursing unless a patient met this “improvement standard.”
Under the terms of the legal settlement, a patient's condition no longer needs to improve to be eligible for skilled nursing care and rehab. She will now be eligible for the Medicare benefit even if that care helps her maintain her health status. As long as skilled care is deemed necessary by a health professional based on an individual assessment, maintenance therapy would now be a Medicare benefit.
It is also important to remember that the settlement does not increase the number of days skilled nursing care is provided after a hospitalization. It remains a maximum of 100 days per benefit period.
The agreement must still be approved by the judge before it is final, however, the federal government will begin implementing the agreement right away, though the process could take many months.
It is long past time for Medicare to clarify this issue, and it could even end up saving the program money since ongoing therapy might keep a patient out of the hospital. However, don’t be confused: This agreement does nothing to expand long-term care benefits.
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