Premature termination of Medicare payments for nursing home residents may be prevented as a result of the case of Jimmo vs. Sebelius Civil Action Number 5:11-CV-17 United States District Court for the District of Vermont. The Jimmo case may allow a Medicare nursing home resident to have their care paid for by Medicare for a substantially longer period of time than was allowed in the past.

The case “discarded” the old “rule of thumb” under which a patient in a skilled care facility had to “show improvement”  Under the new rule there may be specific incidents where no improvement of the patient is expected but skilled care is nevertheless required in order to prevent or slow further deterioration and maintain a beneficiary at the maximum practical level of function.  The underlined words are the key words to appeal a Medicare nursing home payment termination.

When a Medicare patient has their Medicare services terminated a notice is immediately given to the patient or his family representative.  That notice allows for a phone call appeal which must be made within 24 hours.  The appeals are usually determined within a matter of a few days and are done by an independent review of the Medicare Records.  This appeal does not cost the family anything.  In many cases all that may be needed is a statement that an appeal is made because Medicare skilled care (paid for by Medicare) is required in order to prevent a slow deterioration and maintain the beneficiary at the maximum practical level of function.  This may be sufficient language to restart Medicare payment for nursing home care.  Because many nursing home facilities charge over $270 per day any additional days that can be gained on Medicare are very worthwhile to the family involved.  Even after the expiration of the initial Medicare 100% payment which normally is a 20 day period it is worthwhile to strive to maintain Medicare partial payments.  Often the patient has a supplemental healthcare policy which will pay the remaining unpaid portion of the bill for as long as 100 days.

The rule of the Jimmo case is being implemented into Medicare nursing home guidelines.  However, these guidelines may not yet have been distributed to the nursing home where your loved one resides.  Therefore the Jimmo vs Sebelius rule could be an important basis for appeal if your family member’s Medicare nursing home benefits are prematurely terminated.

Submitted by Attorney Douglas Plier of Horicon, Wisconsin.

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Attorney Plier is a longstanding member of the Dodge County Bar Association with many years of experience.
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