A major Federal legal settlement almost two years ago might affect you. Jimmo v. Sebelius.
After a three day hospitalization, Medicare will pay for up to 100 days of skilled nursing (100% for the first 21 days and after that at 80%).
But it used to be that Medicare would stop paying before the 100 days was up if the facility determined that the patient had "plateaued" or was not showing improvement. At that point, the patient would either have to pay out of personal funds or be discharged, even if he still needed nursing care.
Thanks to the settlement reached after Jimmo vs. Sebilius, the standard has changed. Now, as long as the care is reasonable and appropriate, the care will be covered if it is needed to maintain the patient's condition or to slow the patient's decline. This means that millions of chronically ill people who were being cut off Medicare nursing home benefits because their condition wasn't improving are now able to keep the benefits for the full 100 day period.
We recently had to educate my mother's skilled nursing facility, when they were about to discharge her from a skilled nursing facility after only a few weeks, saying that she had "plateaued." She had clearly not plateaued -- her condition had finally started to improve -- but without the new Medicare policy they would have discharged her anyway. Instead, she remained for another five weeks and when she left, she was in far better shape than when they first wanted to discharge her.
There is still a lot of outdated information on the web about this, and many nursing homes haven't noticed that the Medicare manual was updated last year to include the new policy. Bottom line: if a person has a hospital stay that qualifies him for Medicare skilled nursing care, he can continue to get that care paid for by Medicare for 100 days, even if he isn't improving -- as long as he's still benefiting from it and the care is reasonable and appropriate.
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