Premature Termination of Coverage
Medicare offers skilled rehab services to their beneficiaries, which also cover room and board at nursing homes throughout the period of receiving these services. However, for over 15 years, most skilled nursing homes have been prematurely and incorrectly terminating this benefit because the patient has “plateaued” or “is not improving.”
Lawsuits Against Termination of Coverage
This has been the topic of a federal class action lawsuit, Jimmo v Sebelius, (D. VT, 1/24/2013). In this case, the plaintiff, Mrs. Jimmo, was told by her nursing home that her Medicare rehab benefit (and as a result, coverage of her stay at the home), were being terminated due to her lack of progress in her skilled rehab sessions.
After years of litigation, the Court ruled that Medicare rehabilitation coverage does not depend on the individual’s potential for improvement, but rather on their need for skilled care in order to maintain or slow the deterioration of their condition.
What To Do if Your Coverage is Being Terminated
If you or a loved one has been told by a nursing home that Medicare-covered rehab is being terminated because sufficient progress isn’t being made, there are a couple steps to complete.
First, request a meeting with the facility rehab staff, social services’ staff and medical director to advocate for a re-evaluation to determine possible reasons that could hinder their ability to fully participate in their therapy, such as:
therapy at a time of the day when they are tired
a therapist they do not like
an underlying medical condition like the flu
If none of these factors result in a reinstatement of rehab benefits, request a “Demand Bill,” which is an appeal of denied coverage
In over 85% of appeals, patients receive approval of additional Medicare - covered therapy days, so there is a good change your appeal could be approved too!