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Life Health > Long-Term Care Planning

Courts Reject Medicare Skilled Nursing Rules

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Older Americans are entitled to Medicare coverage of skilled nursing home care and home health care, even if they are unable to prove such care would improve their conditions, two federal courts ruled recently in separate rulings.

U.S. district courts in Vermont and western Pennsylvania have held that the U.S. Department of Health and Human Services (HHS) was too strict in enforcing rules covering when individuals are entitled to coverage.

Medicare pays for skilled services for up to 60 days following a hospitalization, if the care is needed Scales of justiceto help with routine activities of daily living, such as eating or dressing, or to prevent the person’s condition from worsening.

The U.S. District Court in Pittsburgh recently upheld an appeal from Wanda Papciak of an HHS administrative law judge’s decision denial of Medicare coverage. Papciak had asked for skilled nursing services after suffering a range of ailments following hip replacement surgery in 2008 and needed treatment so she could walk.

Papciak showed little progress, and she had regressed in some areas. As a result, Medicare denied payment for part of her treatment costs because she was receiving only custodial care, not skilled nursing services.

In overruling HHS, the district court found the law enacting Medicare must be “liberally construed in favor of beneficiaries.”

Medicare also must cover services that maintain an individual’s current level of

functioning, even if no improvement of a given condition is observed, the court held.

In the second case, the U.S. District Court in Burlington, Vt. reversed an HHS decision involving a plaintiff, Sandra Anderson, who had applied for coverage for home health services after suffering a stroke that left her incontinent, cognitively impaired, partially immobile and with a range of other serious ailments.

The claims-processing company that handled the claim for HHS covered Anderson’s therapy for 60 days but denied coverage for remaining treatments, despite a physician’s decision that the treatments were needed. An administrative law judge for HHS subsequently upheld that decision, finding the treatments would probably not improve here condition.

In its Oct. 25 ruling, the district court reversed the decision to decline coverage for Anderson’s subsequent treatments on grounds it was “not supported by substantial evidence.”

The court held Medicare responsible for the cost of services that prevented a worsening of the person’s condition, and not just for services to improve a condition.


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