Medicare Rehabilitation Coverage – There is no “Improvement” Standard

Our clients frequently are faced with a common myth or misconception regarding what nursing home care may be covered by Medicare following a hospitalization when rehabilitation has been prescribed by the patient’s attending physician. Many times providers or insurers erroneously inform families that the patient’s Medicare coverage of the nursing home bills will end because the patient is no longer improving or has plateaued.

There is no “improvement” standard for continued Medicare rehabilitation coverage. The class action lawsuit Jimmo v. Sebelius, settled the issue in favor of the patients/plaintiffs on the issue of Medicare coverage for nursing home rehabilitation even when the patient is not improving. As long as the rehabilitation is medically necessary, coverage can continue up through the 100^th day, even if the rehabilitation merely slows any decline in the patient’s function or helps maintain a level of function. Coverage does not end because the patient has plateaued or is no longer improving. Nursing home administrators should train their staff to raise the staff comfort level that Medicare coverage will continue even with no improvement in the patient’s condition as long as the rehabilitation slows the decline.

Patients and their family members need to learn to be strong advocates for their loved ones who are receiving care in nursing facilities. In some cases, there can be a financial incentive for nursing homes to have a patient come off of Medicare before the 100 day limit is reached for rehabilitative services. However, that is not an appropriate excuse to stop rehabilitation or to tell a family that Medicare will no longer cover the medically necessary rehabilitative care, and the daily room and board rates that goes with the Medicare coverage.

If the nursing facility continues to inappropriately claim that coverage under Medicare must end, then the patient and/or family should seek support from the attending physician. Potentially the physician may need to be unaffiliated with the nursing facility to avoid a bias towards ending rehabilitation too soon. The family may want to ask for a care conference and push for a plan of care that includes the medically necessary rehabilitation services. Keep in mind that the patient does need to be willing to continue the rehabilitation, even if they would prefer not to do so. The patient may be motivated to continue rehab if it is explained that refusal to continue rehabilitation means the Medicare insurance coverage may indeed end prior to 100 days and the patient will have to cover those days by paying privately out of his or her own pocket.

The patient and family may also wish to seek a consultation with one of their attorneys at Strauss Attorneys PLLC. to discuss longer term plans for protecting assets and accessing other potential financing sources for long term care such as Veterans benefits or Medicaid.