Tuesday, November 02, 2010

Medicare rules on paying for skilled nursing care challenged by 2 federal court rulings

Generally, the rule for eligibility for Medicare coverage for skilled nursing care has been that the patient is expected to get better. At least that’s the popular, vernacular explanation. But federal courts in Pennsylvania and Vermont, in widely different cases, have said that such a standard is too strict and that patients may qualify for coverage for skilled nursing care if necessary to maintain stable condition and prevent deterioration that would cause Medicare more medical expenses later.

The New York Times story is by Robert Pear, “Medicare standards are too strict, 2 Courts find”, p A19 on November 19, link here.  One case involved a woman, 81, with hip replacement surgery, and another involved certain home health care services to a 66 year old woman with strokes. Some medical problems, such as multiple sclerosis, may require extensive skilled care just to prevent or delay deterioration.  But not all maintenance care would be regarded as skilled care.

The Obama administration had actually followed the stricter interpretation of the law, often quoted to patients. A group of 17 House Democrats have written the administration urging rules changes. The current political climate, however, may not seem encouraging unless more courts force the issue.

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