Medicare rehab extended
Daily living ability must be considered
November 18, 2010 | 07:02 AM
After suffering a heart attack, a former client underwent a cardiac catheterization and bypass surgery. This same client suffered two strokes following the surgery. After seven days of hospitalization she was transferred to a skilled nursing facility.
After less than 30 days of rehabilitation, this client's Medicare coverage was terminated based on the determination that she had reached a plateau and no longer required skilled nursing care. The client's spouse was not able to care for her at home and there was no safe care plan in place. They were forced to pay privately to remain in the facility for an additional month, incurring a bill of over $15,000.
Medicare is an entitlement program jointly administered by the federal and state governments. Medicare provides varying levels of medical coverage to those who are 65 years of age and older, or under 65 receiving Social Security disability. Whereas Medicaid is a means-based program (conditioned on financial eligibility), Medicare is available to all people over 65, or under 65 and receiving SSD.
One of the benefits Medicare provides is the coverage of rehabilitation after a hospitalization. If a Medicare recipient is hospitalized for a period of three days or more and subsequently requires skilled nursing care, Medicare will cover up to 100 days of rehabilitation in such a facility. The first 20 days of care are covered in full while Medicare covers 80 percent of the cost of each day thereafter.
The key to this coverage has been the Medicare recipient's need for skilled services, that is occupational therapy, physical therapy or speech therapy. This is often the case for patients who have had hip replacement surgery or have suffered a stroke or heart attack. In applying this policy, skilled nursing facilities have been in the practice of advising patients that they no longer require skilled services once they have reached a plateau and are unlikely to improve. As such, it is at this point that the Medicare coverage of a patient's stay at the skilled nursing facility is terminated.
It is not uncommon for my clients to confront premature discharge from a facility in similar circumstances. Family members are typically not ready with a safe discharge plan in order to get the patient home. They often have to choose between paying the facility privately (at rates of $350 to $500 per day) or scrambling to establish a safe care plan for their loved one.
Recently two federal courts have ruled that Medicare will pay for skilled services if they are needed to maintain the beneficiary's ability to perform routine activities of daily living or to prevent deterioration of his or her condition. These decisions are significant because individuals no longer have to prove that their condition will improve in order for Medicare to continue covering the 100-day period of post-hospitalization rehabilitation.
In both cases, the courts held that the facilities were incorrectly applying the legal standard in their denial of coverage of benefits to individuals who they determined had no reasonable prospect of improving. In holding so, it was determined the Medicare rules are to be liberally construed in favor of the beneficiaries.
These rulings are especially significant for beneficiaries suffering from chronic conditions such as Alzheimer's disease, multiple sclerosis and broken hips as well as those recovering from strokes. Improvement should not be a condition of continued coverage. The potential to sustain and preserve current capabilities must be taken into consideration when making Medicare eligibility determinations.
These rulings also encourage patients not to accept the initial determinations and pursue the numerous appeal processes that are available to them with regard to Medicare coverage. When faced with issues relating to Medicare coverage, it is prudent to consult with an experienced elder law attorney so as to ensure that you are exploring all of the options available to you or your loved one.
Nancy Burner, Esq. has practiced elder law and estate planning for 15 years. The opinions of columnists are their own; they do not speak for the paper.