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Clarification of High Profile Medicare Settlement

As most readers know, Medicare is the federal insurance program for seniors. Considering that seniors disproportionately require medical care (after all, health deteriorates in old age), many hospitals rely significantly on Medicare payments for their financial well-being. It is for this reason that Medicare officials have a serious role to play in ensuring sufficient safety standards to maximize patient safety and minimize medical errors. Medicare rules can designate requirements for participation in the program, if hospitals do not meet those requirements, then the facility may not be able to receive Medicare payments. For most faciltiies that is a death knell.

Patient safety advocates often work with the Centers for Medicare and Medicaid Services (CMS) on just this front–ensuring decent quality of care rules are set and enforced. Also, however, those advocates work on basic issues of access to care provided by CMS. This often leads to tension, and sometimes even legal action, between those advocates and CMS. We discussed a recent high-profile example of this last week.

That case involved access to certain at-home services for those on Medicare with chronic conditions. The central issue in that dispute was applicability of a “improvement” requirement for access to those at-home services. Patient safety advocates argued that the requirement that a patient have the potential to improve (instead of just maintain their current level of health) acted to unfairly and illegally deny them proper benefits. Recently, a settlement in that case was reached which will, according to those familiar with the issue, open access to at-home services for those currently on Medicare with chronic conditions. Literally thousands might now have access to services that they otherwise likely would not be able to afford. This will have significant impacts on their quality of life.

Setting the Record Straight
However, in the aftermath of the settlment there has been some confusion about what the agreement does and does not change about Medicare coverage and long-term care. An article from Forbes is helpful in setting the record straight. The author points out that the agreement doesn’t alter anything about the overall payments that Medicare will make for sustained long-term care in a nursing home. As before, Medicare will only cover 100 days of a skilled nursing facility stay, usually for rehabilitative purposes after an injury or illness that required a hosptial stay.

In summarizing the actual changes that will be made as a result of this latest legal action the article suggests that “under the terms of the legal settlement, a doctor no longer has to assert that a patient will improve to be eligible for skilled nursing care and rehab. She will now be eligible for the Medicare benefit even if that care helps her maintain her health status.”

Longer-term stays in a nursing home will still require alternative payment arrangements. In reality, that most likely means that the patient will be required to seek out Medicaid support. Unlike Medicare, Mediaid is based on one’s financial situation. You only qualify if your income and assets are below set amounts. It is not at all uncommon for seniors to be both on Medicare and Medicaid, particuarly if the senior patient requires prolonged nursing home stays that are not now, nor will ever be covered by Medicare.

It is important for all medical patients on Medicare and their families to be aware of these distinctions. The latest is good news for those who care about fair access to medical and caregiving services, but it does not fundamentally alter the Medicare coverage of certain long-term care needs.

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