An often-repeated misconception about Medicare coverage for a person in a nursing home is that supposedly the Medicare recipient must be “improving” in order to qualify for Medicare coverage. This is not the case, has never been the case, but is repeated so often, by so many people, that many think it is the rule.
In January 2013, a US District Court approved a settlement agreement in the landmark case of Jimmo vs. Sebelius which provided in part that the Center for Medicare and Medicaid Services (CMS) was required to confirm that Medicare coverage is determined by a beneficiary’s need for skilled care, not on any potential for improvement. Unfortunately, since 2013, when the settlement was reached, the CMS has been slowed to get the word out to nursing homes, and other facilities, and in 2017, the Jimmo Court required that CMS had to undertake additional measures to properly implement the Jimmo settlement and provide information on the correct standard.
According to a CMS National Survey of providers, nearly one half had never heard about the Jimmo settlement, and about the same number were not aware that Medicare coverage does not depend on a beneficiary’s potential for improvement.
For more details, you can visit the CMS website at: www.cms.gov/center/specialtopic/jimmo-center
Unfortunately, the cost and time delay of appealing an incorrect application of the “improving” standard can discourage most individuals. Therefore, it is important that the institution themselves understand and correctly implement the proper standards.
If you or a loved one are being told that in order to qualify for Medicare coverage in a nursing home you must be “improving”, you can direct them to this resource for correct information. For more information about your rights under Medicare or Medicaid, contact Grosskopf Law Office to schedule an appointment.