Understand basic rules for providing Medicare covered services for chronic, long-term conditions, including maintenance and rehabilitative therapies and services. For information on coverage in all settings visit the Center for Medicare Advocacy’s website: www.medicareadvocacy.org. Click on the “Improvement Standard” link.
Medicare denies you coverage in the nursing home-what now?
The Medicare program often requires an individual to need “skilled” care in order to trigger coverage for both that care and related services. This is true, for example, to obtain coverage for home care, skilled nursing facility care, and outpatient therapies. Skilled services are those services provided by (or under the supervision of ) technical or professional personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech pathologists, and audiologists. Medicare law recognizes that skilled services may include those which are needed to maintain the status of a medical condition or of the patient’s functioning or slow or prevent the deterioration of a medical condition or of the patient’s functioning. You don’t have to be improving!
If a Medicare beneficiary is told that health care or rehabilitation services are to be terminated, request a written notice. The notice should contain the reason for the termination, and should explain the steps necessary to contest the decision. This is needed to appeal a Medicare denial.
To challenge a coverage denial, provide as much information as possible about the need for the care. It is very helpful to have a written statement from the individual’s doctor and other health care providers (physical therapists, etc.) explaining the need for the health care services in question.