Advocacy group wins skilled nursing, therapy suit against Medicare


Does it ever seem to you that we ought to get some manner of recognition for just “making it through?” I mean, we have, presumably, survived Thanksgiving. (If you can’t readily identify what that is behind the leftover cranberry sauce, you probably shouldn’t eat it) and an election!

Congratulations!

Regardless of your reaction to the outcome of the election, most of us reasonably conclude that “ObamaCare” will lumber forward, and rightly so; thus, a reasonable question from Elders and/or Medicare beneficiaries is, “Now, what do I have to do??”

Answer: Nothing. For the foreseeable future, all you need to do is what you were already doing, which is to do your “due diligence” regarding your Part D and/or Advantage Plan, make a decision (or do nothing) and have that in a proverbial bag by midnight on Dec. 7; other than that, put on your seatbelts and prepare for the December holidays.

But while we were busy making ourselves nuts with the election, the Center for Medicare Advocacy (along with a number of other folks) sued CMS (Centers for Medicare & Medicaid Services) which runs, obviously, Medicare and won – Well, they’re winning, because a settlement has been filed in federal District Court and should be formally approved soon. And you would take off your HazMat suit and back away from the refrigerator for this little piece of news. Why?

Here’s the deal: As way too many of us well know, for years and years Medicare has had an “improvement standard” that limited our access to Medicare-paid skilled nursing and therapy services (think, among other things, “Home Health.”) In other words, when you stopped “improving,” services stopped.

…Hmm. So, if I had a condition that was stable, chronic, not improving or that required such services to just keep things from getting worse (“maintenance only”), I was out of luck. Here are two surprises:

1. A lot of us have conditions like that;

2. Said “improvement standard” isn’t in Medicare law!

It was just some rule or regulation or standard or whatever that got injected into the mix somewhere along the way and became gospel; thus, those of us who need such services to keep from getting worse (a reasonable goal, if you’re in that situation) will now have access to them.

Think about that, then say, “Wow!”

The true wonks among us may already have heard of this as the “Jimmo Settlement Agreement,” and if you want to learn a whole lot more about it, go to http://www.medicareadvocacy.org/hidden/highlight-improvement-standard/ and let it sink in. When the Court formally approves the Settlement, CMS will launch a big (I hope!) education campaign aimed at Medicare medical providers AND the rest of us, but the fact is that we could push this NOW – Take a look at the “Self-Help Packet” on that website.

Will this only apply to certain diseases, diagnoses or conditions? No. It applies to any Medicare beneficiary who requires “skilled services” to keep from getting worse.

“Skilled services?” Does that mean “only in a nursing home?” No, it could mean at home, outpatient or in a skilled nursing facility.

Will this add to the number of days that Medicare will pay for in a nursing facility? Good question! No, because the famous “100 days” is specified in Medicare law, but it does change how you might qualify for same.

Won’t this just cost Medicare more and make this whole “healthcare thing” worse? Smart! Well, we shall see, but a study was done through the Veterans Administration model where people had access to services like this and it appeared that it actually cost less, because hospitalizations and nursing home costs went down! Why?

Well, because if we have access to what we need when and where we need it, we tend not to get worse and cost more – Makes sense, huh?

Well, the federal District Court certainly seems to think so.

This will all be unfolding in the next few months, so stay tuned; in the meantime, if you or yours are on Medicare and are denied skilled nursing and/or therapy services because you’re not “improving,” say “Jimmo Settlement” and argue about it, because allowing people to get worse doesn’t save anybody any money.

And remember that this is Medicare, so it’s national, so this is all just as true for Cousin Clem in Kansas City as it is for your sister in Sappho, OK?

“Improvement” can be a relative thing. This is an improvement.

Mark Harvey is the director of Senior Information and Assistance for Olympic Area Agency on Aging. He can be reached at harvemb@dshs.wa.gov or 532-0520 in Aberdeen, (360) 942-2177 in Raymond or (360) 642-3634. FACEBOOK: Olympic Area Agency on Aging-Information & Assistance.