From the Capitol: Medicare for You and Your Loved One

June 2, 2014

Navigating the Medicare system can be overwhelming, intimidating and, at times, very frustrating. In the hopes of making Medicare education more accessible to everyone, local legislators will be hosting a special presentation this month. Judith Stein, Executive Director of the Center for Medicare Advocacy and member of the Federal Commission on Long Term Care will be speaking at the Stratford Library on Tuesday, June 17 from 3-5pm. Stein is one of our nation’s leading experts on Medicare and long term care.

The presentation will cover two very important Medicare issues: the impact of the Jimmo v. Sebelius court case and an explanation of what “Observation Status” means.

Have I lost you yet? Here are the basics of what you need to know about each issue currently impacting those covered by Medicare.

Jimmo v. Sebelius

The Jimmo v. Sebelius court case settlement agreement clarifies how skilled-care is covered by Medicare. In the past, Medicare contractors sometimes denied people coverage for skilled care if they saw no improvement in the person being treated. This “Improvement Standard” was not authorized by Medicare, yet it was being used anyway, and resulted in countless denied claims that should have been covered.

The Jimmo v. Sebelius settlement clarifies that coverage cannot be denied just because there is no potential for improvement in a patient’s condition. Although in some cases a person’s medical status may not be expected to improve, that does not mean skilled care is not needed.

While the court case was settled over a year ago, the government is still working to educate all Medicare contractors about this. The lesson here: know your rights and be vigilant. You cannot be denied coverage just because the care you receive may not lead directly to improvement.

Observation Status

Observation status is a designation used by hospitals to bill Medicare. When a person with Medicare coverage goes into a hospital, if they are admitted for a qualified stay, they can stay in the hospital for 3 days and, upon discharge, Medicare will pay for up to 100 days of care in a skilled nursing home. On the other hand, if a person stays in the hospital under an “observation status” they can stay 5-7 days, but after that period of time they are not qualified for any care in a nursing home.

Knowing this difference is important. This year the Connecticut legislature approved a new law, which I supported, that requires hospitals to provide patients with notice if they are placed in observation status. The hope is that if patients know about their rights, they or their family members can advocate for admission for a qualified stay, instead of observation status, if they believe extended care will be needed. Unfortunately, Connecticut cannot change the federal law that denies nursing home care to those under observation status, but notification is a step in the right direction.

To learn more about these and other Medicare developments, I encourage you to attend the upcoming presentation with Judith Stein. To reserve a seat contact [email protected] or 860-240-8862. Medicare is a complex system, and educating yourself about these intricacies is crucial to getting the best care for you and your loved ones.