Learning the ins and outs of Medicare benefits can leave beneficiaries and their families more than a little frustrated.  Especially when there are misunderstandings among the facilities offering care. Luckily, a landmark lawsuit a year ago brought attention to the blurred lines of coverage for rehabilitation services.

The case was Jimmo v. Sebelius, and it became the subject of a recent Forbes article titled “When Medicare Will Pay for Skilled Nursing or Physical Therapy.

The Jimmo case focuses on what has for many years been considered one of the guiding principles of Medicare.  This principle is the so-called “improvement standard.”  The idea was that Medicare would pay for skilled nursing care or physical therapy only when the patient’s health had the potential to improve.  Accordingly, the payments would cease when there was no more improvement to be had.

Problem: skilled nursing and physical therapy are not necessarily just for curing a problem, but for managing it, especially among the elderly.  Jimmo, however, holds that payment for these services will be made if they are “reasonable and necessary to prevent or slow further deterioration” and that benefits “cannot be denied based on the absence of potential for improvement or restoration.”

Real changes have been slow as providers test the waters, and many other rules regarding skilled care come into play in each specific case.  Nonetheless, an apparent misunderstanding has been put to rest, and an entire class of patients can now be assured of receiving benefits. Those previously denied benefits may even have the option of having their coverage re-reviewed.

Reference: Forbes (January 31, 2014) “When Medicare Will Pay for Skilled Nursing or Physical Therapy

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