The Farr Law Firm assists our Level 4 clients with first-level Medicare Appeals via telephone when a nursing home is threatening our client with a discontinuation of needed Medicare benefits. The nursing home patient must have been admitted for at least three days in the hospital (note that “observation status” does not count towards those 3 days), and the nursing home stay must commence within 30 days of the hospital discharge.
Please note that Medicare does not pay for nursing home long-term care if that’s the only service needed in a nursing home. See http://www.medicare.gov/coverage/long-term-care.html which says that “Medicare doesn’t cover long-term care (also called custodial care), if that’s the only care you need. Most nursing home care is custodial care.”
Medicare does, however, pay for short-term therapy and skilled care in a nursing home for up to 100 days. Skilled care includes physical therapy, occupational therapy, speech therapy, wound therapy, and observation of changing conditions. Medicare will also pay for physician-authorized skilled care provided to a home-bound beneficiary on a short-term intermittent basis.
The Jimmo v. Sebelius Settlement Agreement – Program Manual Clarifications (Fact Sheet) — containing the rules that the nursing homes are supposed to follow — can be found here.
Please see our following article: Important Medicare Change: Patients No Longer Need to Show Progress to Receive Nursing Coverage.
To appeal what you believe is an improper Medicare termination in a nursing home, please download one of these self-help packets: