A Personal Note From Susana
This month’s newsletter focuses on the fiscal issues presented in “The Greenbook” a document created by the US Department of the Treasury to explain the revenue proposals in the President’s proposed budget for Fiscal 2024. The items described have a way to go before being enacted as law, but it is a predictor of what may be coming our way! It is not here yet and may be so theoretical that it will never be the way things come to pass. The Greenbook proposals do not necessarily relate to what you and I are experiencing today, or what will even come to pass in the future.
I would like to counter this possibility with an Elder Law reality that is here today and that does relate to costs in a skilled nursing facility. Medicare coverage, in the context of payment for a resident in a skilled nursing facility exists in a limited way for a short period of time. It is still terribly misunderstood—to the detriment of nursing home residents and their families who believe they are “covered” completely because they have Medicare.
First: Medicare is limited, with respect to a recipient residing in a skilled nursing facility, and does not entirely cover long term/custodial care. EVER.
But for a limited time, you may have Medicare coverage in the circumstance of a need for rehabilitation in a skilled facility that provides it.
Second: The use of the Medicare program within the context of a skilled nursing home setting is dictated by a decision in a case known as Jimmo v. Sebelius. (2013) In this case the court confirmed that Medicare coverage in a skilled nursing facility is to be determined based upon a Medicare beneficiary’s need for skilled care NOT THAT INDIVIDUAL’S POTENTIAL FOR IMPROVEMENT. The Jimmo case confirmed the law that coverage of skilled nursing /therapy is available to anyone who needs those services to MAINTAIN OR SLOW DETERIORATION. Coverage of skilled nursing or therapy is available to that person regardless of the underlying illness, disability or injury.
So, if you or a loved one are told that your Medicare coverage has lapsed because there “has been no improvement” you are being presented with the wrong standard to determine the continuance or cessation of Medicare coverage. You may speak up and cite “Jimmo,” as the standard that the facility should go by is that coverage of skilled nursing or therapy is available to anyone who needs those services to maintain or slow deterioration — regardless of the underlying illness, disability, or injury.”
Third: The Center for Medicare Advocacy has recently updated its fact sheet to outline Medicare beneficiary rights when it comes to Medicare coverage in a skilled nursing facility. This fact sheet may be obtained by requesting it from The Center for Medicare Advocacy, P.O. Box 350, Willamantic, CT 06226, Phone: (860) 456-7790.
I hope this information is helpful to the reader of this note.