Jimmo vs. Sebelius On Skilled Nursing

Skilled Nursing Care is amazingly complex. Because the Medicare coverage of Skilled Nursing Facility stays is so confusing, patients sued.  The case went all the way to the Federal Courts. Jimmo vs. Sebelius, a class-action lawsuit, challenged the Center For Medicare & Medicaid Services (CMS) interpretation of the “improvement stand” that many used to interpret Medicare coverage of Skilled Nursing Facility booklet.

Medicare Coverage of Skilled Nursing Facility Stays: Improvement Standard

This one hit home for me because of how it affected my mother and our family. My mother was in the last stages of ovarian cancer. It became clear that no treatment was going to work. She was on palliative care. During one of her episodes, she was in extreme pain. The hospital admitted my mother because intravenously administered pain killers were the only way to get her pain under control. After that, she was supposed to come home. But her condition was such that we were not going to be able to care for her adequately. We talked about a nursing home—skilled nursing—but one of the criteria at the time was the patient must be able to improve. Because she was terminal, improvement was definitely not in the cards. We were initially told that Medicare would not pay for her stay in a skilled nursing facility. However, that was not accurate. The people we were talking with were operating off old, outdated information.

Slow Deterioration of a Condition

On January 24, 2013, the class action lawsuit Jimmo vs Sebelius settled in favor of the patient, and the Center for Medicare & Medicaid Services (CMS) clarified its policy.  Medicare coverage of Skilled Nursing Facility stays no longer required “improvement.”  Instead, care could be prescribed to maintain the status of an individual’s condition, or slow the deterioration of a condition, as well as to improve the person’s condition.

Jimmo Website Explains New Medicare Coverage

As ordered by the federal judge in Jimmo v. Sebelius, the Centers for Medicare and Medicaid Services (CMS) published a new webpage containing important information about the Jimmo Settlement on its CMS.gov website. The Jimmo webpage is the final step in a court-ordered Corrective Action Plan.  The action reinforces the fact that Medicare does cover skilled nursing and skilled therapy services needed to maintain a patient’s function or to prevent or slow decline. Improvement or progress is not necessary as long as skilled care is required. The Jimmo standards apply to home health care, nursing home care, outpatient therapies, and, to a certain extent, for care in Inpatient Rehabilitation Facilities.

In my mother’s case, the skilled nursing facility admitted my mother, even though she was terminal, to help slow the deterioration of her health. As it turned out, she passed away within two weeks of her admittance, and the personnel at her skilled nursing facility were outstanding! They made her last days as bearable as the situation would allow.

Medicare Coverage of Skilled Nursing Facilities Changed

Medicare coverage of Skilled Nursing Facility stays practices have changed.  Researchers assessed the impact of the Jimmo settlement by looking at changes to the number of physical therapy and/or occupational therapy visits per year, per patient, focusing specifically on the number of individuals who had 12 or more therapy visits during a 12-month timespan.

Healthcare is very expensive. There are many conflicting groups and interests. The rules, policies, and mechanisms are complex. Some of the people you deal with can be frustrating. The complexity of the system is driven home to me daily as I talk with clients and deal with issues that arise. You need to be aware of the rules and regulations around Medicare coverage and nursing home care. Or have someone who knows them and can help.

My Mother’s Life Expectancy

The doctors diagnosed my mother with ovarian cancer in 2012.

I was living in Kansas at the time.  I wasn’t able to go on doctor visits with her.  My brother, Paul, was taking care of my mom.  I would get information about her situation, but it was spotty.

My mother was definitely an ‘I’m in charge’-type person.  Phyllis determined the flow of information, and it was sparse.

Talking with your mother about her health when her mortality is so tightly fixed to it is hard.  Looking back now, I was a coward. I should have been more direct.  I didn’t realize the seriousness of her situation until much later.

She didn’t speak of her death, I assumed, because she didn’t want to worry us though I am sure she was struggling with her own denial.

At the end of 2012, the doctors said there was nothing more to be done.  I don’t think I fully grasped what that meant at the time.  I also did not anticipate how quickly time would slip away from that moment onward. I’m sure my mother was scared, but she didn’t let on.

I stupidly didn’t realize the magnitude of the moment and how she was probably feeling.  My own feelings and denial fogged the situation.

My mother was admitted to hospice care (Medicare Hospice Benefits Booklet).

Medicare Hospice Benefit

Hospice care is a benefit under Medicare Part A. To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. An individual is considered to be terminally ill if the medical prognosis is that the individual’s life expectancy is six months or less if the illness runs its normal course. Only care provided by (or under arrangements made by) a Medicare-certified hospice is covered under the Medicare hospice benefit.

The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient’s attending physician.

Mom’s Terminal Illness

Nature, in its less than glorious side, took its course rapidly.  My mother’s health deteriorated in a few short weeks.

Cancer is a painful disease. The health care personnel gave her various pain killers, but even as they did so, we all insanely talked about not wishing to cause addiction.  The pain had its own mind.

At various times, my mother’s suffering would be such that she needed to go to the hospital.  There the doctors could administer intravenous medications that were faster acting and could stabilize her level of pain.

During the last visit, it became clear that we could not take care of her at home.  My father, John Grimmond–who would pass away six months later–was not physically able to care for our mother. I was in Kansas, my other brother, Tom, was in Sioux Falls, and Paul was in Omaha but busy with career and family.

My mother needed around-the-clock care. We asked ‘does Medicare pay for hospice in a skilled nursing facility?’ Medicare pays for hospice in a skilled nursing facility, but Medicare does not strictly pay for custodial care. That is, it will not pay for bathing, feeding, going to the toilet, etc.

How To Help Mom With Medicare On Hospice

The staff at the hospital initially told us that our mother needed to go to a Skilled Nursing Facility (SNF) because they recognized she required more care than we could provide. They informed us that Medicare would provide and pay for hospice care in the Skilled Nursing Facility, but the cost of room and board and custodial nursing care would not be covered, and they were correct. Medicare coverage for hospice care is tricky at best.

The fortunate occurrence, however, was the intravenous nature of her painkillers triggered a reason for skilled nursing care. Medicare does cover skilled nursing care after a qualifying hospital stay of 3-days or more. But does Medicare cover hospice in a skilled nursing facility? Intravenous medication administration requires skilled nursing care.

A home health care nurse showing up a couple of times at home would not be adequate to the task. Also, she needed physical therapy to improve her strength after the reaction to the pain. Those were sufficient reasons for Medicare to cover her stay in the skilled nursing facility (SNF) and to pay for even the room and board.

Does Medicare Pay For Skilled Nursing Care During Hospice?

Does Medicare pay for hospice care in a skilled nursing facility?  Strictly speaking, Medicare does not pay for skilled nursing care because someone is in hospice, but many times there are other triggering events that cause Medicare to cover skilled nursing care.

For example, someone who is in hospice falls and breaks a hip.  That situation would justify skilled nursing care.  A person develops an infection or pneumonia that results in hospitalization.

But what about someone who needs palliative care, or inpatient respite care at an inpatient facility? How do you do symptom management?

There are so many questions to ask. Does Medicare cover hospice care for the terminally ill? Does Medicare pay for inpatient hospice care? What are the hospice care qualifications for Medicare?

The hospice patient is transferred to a skilled nursing facility to continue the care.  In those ways, skilled nursing and the custodial care of a hospice program that accompanies it are available.

Burying a mother is one of those milestone events in our lives. While dealing with all the emotional, spiritual, financial challenges that accompanied that moment, health care cost was not a burden to my family and me. Medicare and my mother’s Medicare plan took excellent care of her and us. I am grateful for such a wonderful program and the insurance that worked with Medicare.

Phyllis Grimmond 1935-2013 R.I.P.

People constantly ask me, ‘What should I do about Medicare?’  They are overwhelmed with all the brochures from insurance companies.  They look through the 162 pages of the Official Medicare Handbook and are further confused.  Some go to the Medicare.gov website, and are confounded in attempts to navigate through the endless ocean of information.  They simply ask in bewilderment, “What does everyone else do?’  A huge number of people choose a Medicare supplement, or Medigap plan, as the solution, but more of an answer is needed than just ‘everyone is doing it.’  Some thoughtful consideration is required.

Part A Deductible

Medicare is a generous health plan.  It covers a majority of the hospital and doctor costs, but there is some important exposure to be aware of.  Medicare Part A covers the hospital, but only after you pay the deductible of $1,288.  That deductible is not an annual deductible.  It is per event within a 60 day period.  While you would have to be very unlucky, very sick, or both, you could pay that deductible an endless number of times.  That is your exposure.

Part B Co-Insurance

Medicare Part B covers 80% of the doctor and outpatient procedures.  While that is quite generous, 20% of a big number is still a big number.  Heart attacks, strokes, cancer treatment can run into the hundreds of thousands of dollars.  Twenty percent of a $200,000 bill is $40,000.  Most people would find that beyond the family budget.

MOOP

And with Part A & B, there is NO maximum-out-of-pocket (MOOP).  In other words, you continue to pay as the bills roll in.  You do not stop paying on deductibles and co-insurance if all you have is Original Medicare without anything else.

So comes the questions from clients: ‘What should I do about Medicare?’  Medicare supplements or Medigap plans fill in those gaps in Medicare.  They cover the hospital deductibles and 20% co-insurance for doctor and outpatient use.  Depending on how much you wish to cover, the Medigap plan can cover everything 100%, most of everything, or a potion.  You choose.  There are ten plans available.

12,200,000 Satisfied Medigap Clients

The fact that 22% of people on Medicare choose a supplement and stay on a supplement for 20-30 years tells you the level of satisfaction.  There are currently 55,200,000 Medicare beneficiaries.  Of that number 12,200,000 chose a supplement.  That number grows each year: 9.7 million in 2010 to 12.2 million in 2015.  The key number is that 9 out of 10 Medigap beneficiaries say that they are satisfied with their coverage and keep their coverage.  Med Sup Conference Stats

While Medicare is a wonderful health insurance program for seniors, it doesn’t cover everything.  You still have exposure to significant financial loss if you only have Medicare alone.

One of the things that holds people back from purchasing a Medicare supplement is that they don’t know.  That is, they don’t investigate what Medigap plans are, what the costs are, how much or little they cover.  It is simple as making a phone call 402-614-3389.  A quote will not cost you anything, but you will have some real, solid information for your decision making process.  Take a couple minutes, answer a few questions, and you will be surprised how easily you can find out what you should do about your Medicare @ OmahaInsuranceSolutions.com.

The Affordable Care Act (ACA) has brought many questions to business owners and individuals alike. What plan is the best? What kind of healthcare will you qualify for? Will you get to keep your same doctors? For those who are retired or close to retirement, the subject can be even more complicated. When you retire or turn 65, do you have to enroll in a Medicare Plan?

Essentially, yes. Joe Baker, president of the Medicare Rights Center, a national, nonprofit advocacy organization, warns that if you don’t enroll in Medicare at the age of 65, “you don’t have primary coverage, which means that you basically don’t have coverage for most of your healthcare needs.”

Many individuals are confused by this, perhaps rightfully so. The fact is, although your health insurance plan bought through an ACA marketplace will not automatically end when you turn 65, its coverage decreases dramatically. The message that Baker and other Medicare professionals are trying to get out to the public is that these individuals who are currently covered by the ACA before turning 65 must enroll in Medicare once they reach that age.

Now, it is important to realize that if you’re 65 or older and are covered by large-employer insurance, this rule doesn’t apply to you; however most people in this situation should at least take Part A, which is hospital insurance. Without this exception however, new Medicare enrollees must apply at least four months after they turn 65, otherwise they’ll have to wait until the next open-enrollment period, with no coverage in the meantime.

Timing is also important when switching from the ACA Marketplace to Medicare coverage; with individuals being warned to take care when they discontinue their exchange coverage as to not leave a gap between that coverage and Medicare enrollment.

The licensed insurance agents at Omaha Insurance Solutions are here to answer any of your questions you may have about Original Medicare, an Omaha Medicare Advantage Plan, and any other Medicare concerns you may have. Please contact us today at (855) 367-3631.

You can also find more information at Medicare.gov.