Although Medicare does not cover many nursing home stays, Medicare will provide up to 100 days of coverage for nursing home care if the Medicare beneficiary was admitted to the nursing home after an inpatient hospital stay of at least 3 days, the patient needs the skilled care provided by the nursing home andcertain other Medicare requirements are met.
Previously, nursing homes had interpreted the Medicare rules as requiring that a patient receiving skilled nursing home care must be improving in order to be eligible for the 100 days of Medicare coverage. This was called the “Improvement Standard.” Many patients who still needed skilled nursing home care to maintain their functioning had their nursing home Medicare benefits terminated before reaching the 100 day limit because of the Improvement Standard.
In response to a recent lawsuit, Jimmo vs. Sebelius, the Centers for Medicare & Medicaid Services (CMS, which administers Medicare) agreed that the Improvement Standard does not apply to skilled nursing home care coverage. Medicare beneficiaries will now be eligible for up to 100 days of skilled nursing home care per benefit period as long as that care is reasonable and necessary to prevent or slow further deterioration and they meet the other Medicare requirements for skilled nursing home coverage. Click here to view a copy of the Settlement Agreement.
In addition, any Medicare beneficiary who was denied coverage for skilled nursing home care after January 18, 2011, due to the Improvement Standard will be able to file a request for their claim to be reconsidered. CMS will be conducting a nationwide educational campaign to educate Medicare providers and beneficiaries about this new policy. Once the educational campaign is finished, a procedure will be put in place for beneficiaries to request retroactive reconsideration of denials issued after January 18, 2011.
Additional information and resources can be found on the website of the Center For Medicare Advocacy, Inc.
To learn more about the Medicare requirements for coverage of nursing home stays, visit the official Medicare website, Medicare.gov.