When does Medicare pay for long-term care treatment?

For many years, the general rule on whether Medicare would pay for the cost of a stay in a long-term care facility was as follows:  if the person spent 3 “midnights” in a hospital then went to a long-term care facility for therapy for the same ailment within 30 days of leaving the hospital, Medicare may pay for the first 20 days in the facility in full then part of the cost for the next 80 days.  The patient would have a co-pay for those 80 days of $161 per day.  Once the 100 days expired, Medicare paid no more of the cost at the long-term care facility.

However, there was no guaranty that Medicare would pay for those 100 days.  Medicare would review the medical reports coming from the long-term care facilities during this time period and may have determined that the patient’s condition was not improving from the treatment (usually rehab) received.  Medicare would then advise the patient and the facility that the patient reached a “plateau” and would discontinue payment for the rehab.

Nearly 4 years ago, a woman named Glenda Jimmo challenged this standard in a federal lawsuit.  The result was a new standard:  that no longer would the patient have to show improvement for Medicare to keep paying for the rehab, but they would have to pay for the rehab as long as the rehab was necessary to maintain the patient’s current condition or prevent or slow further deterioration. In other words, under the new standard, the patient did not have to show improvement in their condition like the prior standard.

medicareOver the past few years, there has been much confusion on which standard to apply and how to interpret the Jimmo standard.  In fact, Medicare has been pushing hospitals to keep patients in “observation status” rather than admitting them.  By being in observation status, the time the patient is in the hospital does not count towards the 3 midnight stays to qualify them for Medicare payment for rehab once they went to a long-term care facility.

Last month, a federal judge gave the Centers for Medicare and Medicaid Services 2 months to come up with a better plan to educate providers of rehab, auditors and patients about the maintenance standard.  Until this plan is revealed, providers and patients must deal with the confusion surrounding the current standards.  If you are confused and have about this or other Elder Law concern, please contact Joe Mattera at jmattera@pselaw.com or call 937-223-1130.



AUTHOR: Joseph Mattera

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