Medicare and Skilled Nursing after Jimmo v Sebelius: An Analysis of When Medicare Will Pay for Skilled Nursing or Physical Therapy

In this current event report, a summary and analysis will be conducted of the article When Medicare Will Pay for Skilled Nursing or Physical Therapy by Howard Gleckman published in Forbes magazine, January 1, 2014. As technology and policy changes have transformed the landscape of nursing care over the past 15 years, it is important to examine the ever-evolving relationship between government funding and nursing providers. Medicare provides funding for 16% of all patients in the United States (Kaiser Family Foundation, 2012). The government provides an essential safety net in order to provide nursing care for those in serious need. However, cost-cutting measures and a large number of Medicare beneficiaries meant that skilled nurses have not received the funding needed to provide the utmost level of care to their patients and achieve better patient outcomes (Gleckman, 2014). In order to ensure proper funding levels in the future, nurses, administrators and patients themselves need to be aware of the recent court ruling Jimmo v. Sebelius which clarifies that despite denying such claims in the past, Medicare cannot deny payment for a patient's use of skilled nurses for services that will not necessarily result in an “improved condition,” but will instead prevent a patient's condition worsening (Center for Medicare Advocacy, 2014). This landmark decision will benefit both skilled nurses and the Medicare patients they care for in the fields of home health, managed care, physical, occupational, and speech therapy (Gleckman, 2014).

In 2011, a class-action lawsuit was filed by a 76-year-old blind amputee from Bristol, Vermont named Glenda Jimmo on behalf of all Medicare beneficiaries who had been denied coverage because of Medicare's so-called “improvement standard” rule of thumb (Miller, 2012). Patients suffering from chronic illnesses whose symptoms could not be “improved” by treatment from skilled providers were repeatedly denied benefits prior to this court ruling. Previously, patients were required to use unskilled healthcare providers, rather than nurses, unless it could be demonstrated that their condition would directly improve (Gleckman, 2014). This current event is important because the settlement is now fully coming into effect in 2014. Any nurse who has cared for a patient with a chronic condition who is receiving Medicare benefits understands how difficult it can be for patients and families when coverage is denied and these essential support services are terminated to the detriment of the patient.

In light of this ruling, patients can now access skilled nursing care when they are needed to “prevent, or slow deterioration” and “the beneficiary requires skilled care for services to be safe and effective.” Coming from the other direction, care may not be denied based on “lack of restoration potential” or patient conditions which are “chronic, terminal” or expected to be long-lasting (Lipschutz, 2013). Instead, Medicare reimbursement should be based on an individual assessment of the patient's needs which can then incorporate skilled nursing care into a long-term maintenance plan.

Due to the slow-moving nature of large government agencies, the full implementation of this 2013 court ruling has only now come into effect in the form of revised CMS manuals, training and policy revisions. However, “the settlement agreement goes back to the date the case was filed, January 18, 2011.” (Center for Medicare Advocacy, 2014) This means that if coverage was denied during this period, a “re-review” can be undertaken in order to retroactively provide benefits denied because of the “improvement standard.” This information is important because, in order to be properly paid by Medicare, different types of nursing providers must adhere to specific guidelines.

Medicare will only pay for 100 days of skilled nursing care at a facility per benefit period, and this has not changed in light of the Jimmo ruling (Gleckman, 2014). Skilled nursing facilities will need to hospitalize a patient for 3 days prior to administering skilled nursing therapy. (Center for Medicare Advocacy, 2014). The daily skilled care required to receive Medicare benefits is five days per week of speech, physical, or occupational therapy or seven days per week of nursing or nursing and therapy combined. Nurse administrators working for nursing care facilities should understand that therapy must be given daily in order to qualify for Medicare reimbursement in light of Jimmo v Sebelius (Lipschutz, 2013). Skilled nursing facilities may be wary of providing this level of care based on previous Medicare denials, but the Center for Medicare Services assures beneficiaries that they will be reimbursed fully if they follow the aforementioned rules. Standing in contrast to the hefty requirements of skilled nursing facilities, other nursing contexts have their own guidelines.

In order to qualify for Medicare coverage, patients who utilize skilled home health providers must ensure that the services rendered adhere to certain specifications. The care must be ordered by a physician and take place under a written plan of care. “The beneficiary must be confined to home,” though this does not mean bedridden (Lipschutz, 2013). The skilled home care provided can be administered as little as one day every two months, up to daily care which takes place for a specified period of time. For patients who are receiving outpatient therapy, there is a limit of $1,900 per year (Lipschutz, 2013).

Medicare is still undergoing the transition toward better providing skilled nursing care benefits due to the court's approval of the settlement offered by the office of Health and Human Services in Jimmo v Sebelius (Gleckman, 2014). Some patients should expect that their claims will be denied, but they should not be discouraged. The appeal process can reverse a previous denial and reimburse patients for nursing care they have already received. Nurses should always act as patient advocates, relaying information to doctors, facility administrators, social workers, and other members of the healthcare team. When a patient states that their benefits are being denied, it is important for nursing staff to alert the doctor to see if he or she can intervene and take part in the Medicare approval and appeal process. Skilled nursing care cannot be provided without funding, and many facilities remain apprehensive about taking on Medicare patients because of past denials of coverage. Nurses need to work together with doctors and patients to ensure that they receive high-quality care and that the facility or nursing provider is properly reimbursed by Medicare.

References

Center for Medicare Advocacy, Inc. (2014, February 21). Judge approves settlement in Jimmo v Sebelius after court hearing. Retrieved February 28, 2014, from http://www.aanac.org/docs/reference-documents/medicareadvocacy.pdf?sfvrsn=0

Gleckman, H. (2014, January 31). When Medicare will pay for skilled nursing or physical therapy. Forbes. Retrieved February 28, 2014, from http://www.forbes.com/sites/howardgleckman/2014/01/31/when-medicare-will-pay-for-skilled-nursing-or-physical-therapy/

Kaiser Family Foundation. (2012). Medicare beneficiaries as a percent of total population. Retrieved February 28, 2014, from http://kff.org/medicare/state-indicator/medicare-beneficiaries-as-of-total-pop/

Lipschutz, D. (2013, March 21). The Medicare improvement standard – Implementing the Jimmo settlement. Center for Medicare Advocacy, Inc. Retrieved February 28, 2014, from http://www.healthlawyers.org/Events/Programs/Materials/Documents/MM13/lipschutz_slides.pdf

Miller, M. (2012, March 27). Landmark Medicare settlement could change lives. Reuters. Retrieved February 28, 2014, from http://www.reuters.com/article/2012/10/27/us-column-miller-idUSBRE89Q0CN20121027