The Elderly & Special Needs Patients and the Fiscal Cliff

January 9, 2013

Filed under: Uncategorized — Alexis @ 10:46 AM

In all the fiscal cliff nonsense of the last few weeks, here are a few provisions that affect the elderly and the disabled:

1. Remember how doctors were being threatened with a 27% pay cut for their Medicare patients? That threat went away. For a year. Set your clocks now for December 2013 when we get to watch this debate all over again.

2. Extension of the Medicaid payment of the Medicare Part B deductible for low-income folks. That’s the $99.90 that is deducted from your Social Security check every month. For low-income folks, Medicaid picks up payment for Medicare Part B. That was threatened to disappear. It’s been saved… until December 2013, anyway.

3. CLASS has officially been repealed. This was Ted Kennedy’s project, it was the first national response to our long-term care funding crisis. Lots of folks didn’t like it right from the beginning. Now it’s gone, and so far we still don’t have a national agreement on where we stand as a society on providing for long-term care.

4. Creation of the Commission on Long-Term Care. This outfit is supposed to develop recommendations for a national approach to establishing, implementing,and financing a long-term care system that establishes quality long-term care and supports. American history is littered with study groups whose recommendations and good work are ignored by Congress (sometimes for the good). We will wait to see who is appointed to this commission before we can predict whether their recommendations will be thoughtful and balanced or stilted in one direction. If the Commission is to be staffed in the thoughtful and balanced direction, then I expect that NAELA will advocate to have one of our knowledgeable thought leaders involved.

The Nursing Home Stopped Medicare Payments Because my Loved One Stopped Improving, but I Heard that’s Illegal

January 3, 2013

Filed under: Medical Care — Alexis @ 10:52 AM

For many years, Medicare has stopped paying for therapies or skilled care once the patient stopped improving, or plateaud.  This is not what the regulations say, but somehow that became the practice across the country.

In December, the good folks at the Medicare Advocacy Project fought and won against this trend, and a federal judge ordered that nursing homes must now provide the full 100 days of coverage that patients are entitled to, so long as they need skilled care or therapies, whether to improve, to maintain their conditions, or to stop or slow a deterioration.

So what happens to patients who have received Medicare denials in the past few years, and had to pay out-of-pocket, often impoverishing themselves, so that they (or a loved one) could receive continued nursing home care?  Will this federal case help them?

Yes. Denials going back as far as September 20, 2010 can be re-reviewed under the new (old) standard.  So if you or a loved one were in a nursing home in the late summer of 2010 or later, and if you had to pay out-of-pocket for skilled care or therapies after a Medicare denial, then dig out your paperwork.  As the federal case is implemented, Medicare will create a process for re-reviewing these denials in light of the new (old) standard.  Check the Medicare Advocacy Project for updates on this process.

If you have a loved one currently in a nursing home and they receive a Medicare denial, if you think they need continuing skilled care or therapies in order to maintain their condition or to stop or slow their deterioration, then appeal.  It will take some time for the appeal process to get up and running, but you want to make sure you appeal on time.

P.S. These rules also apply to home care and outpatient therapies.