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Clearing Up Misconcpetions About Medicare Settlement

We recently discussed the details of an important settlement in a class action case filed by various advocates against the federal Medicare program. The basis for the suit was the contention by the advocates that Medicare unfairly (and unlawfully) denied benefit coverage for at-home services to those whose condition was unlikely to improve. Medicare officials denied that this “improvement” standard ever existed. However, those working with Medicare participants with disabilities explain that in practice many individuals who need at-home support were denied that help because they were deemed to have chronic conditions that would not improve.

For example, the lead plaintiff in the case was a woman who is blind and has diabetes. Complications from the diabetes caused her to lose one of her legs and four toes on her other foot. Yet, depsite this, she was rejected coverage by Medicare for nursing help at her home. That is becase she likely wouldn’t “improve”–apparently maintaining current health levels was insufficient.

Fortunately, the woman fought for her rights. A lawsuit was eventually filed, spearheaded by many advocates for seniors and those with disabilities. That suit was finally settled, with the Medicare program agreeing to alter policies such that the woman leading the case–and others similarly situated–will qualify for the at-home care that they need. This should not be underestimated. “Maintenance” support is still incredibly important, with real world impacts on the quality of life for thousands of seniors. This ruling means that these individuals will be far more likely to have the extended support they need–like at-home nurses–to maximize their well being depsite their permanent medical setbacks.

Nursing Home Coverage
However, it is important to clear up one issue about this settlement that has confused some community members. This settlement does not mean that Medicare will suddenly cover extended nursing home stays for seniors. As in the past, Medicare generally does not cover nursing home stays unless they are short-term rehabilitative stays. If one needs nursing home care, the Medicaid system is the only public option for support. The Medicaid system is based on income level. That means that the senior in need of care will likely have to “spend down” assets before qualifying
A recent article in Forbes provides a helpful discussion of these issues. As the author put succinctly: “Medicare did not pay for long-stay nursing home care, home health aides, or other long-term care services before this lawsuit, and it will not do so now.” The story also reminds readers that the settlement does not change the fact that Medicare will only pay for up to 100 days in a skilled nursing facility per benefit period. This refers to rehabilitative stays, generally, and not those situations where an ailing senior is forced to move into one of these facilities because of systematic health problems and concerns.

To have help with these elder law issues, be sure to seek out a professional to understand how payments and insurance coverage works in these situations.

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