San Juan Basin Area Agency on Aging News: Medicare coverage for skilled nursing and skilled therapy

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By Kay Kaylor
SUN Columnist

I advocate for residents in extended care and assisted living residences as the region’s lead long-term care ombudsman. I also am a Senior Medicare Patrol and State Health Insurance Assistance Program counselor, all as an employee of San Juan Basin Area Agency on Aging (SJBAAA). Information on the many aging and care concerns will be included here.

July marked the 55th anniversary of Medicare and Medicaid and the 30th anniversary of the American with Disabilities Act. As the Center for Medicare Advocacy (CMA) notes in a July 30 Alert, “These landmark laws have vastly improved the lives of Americans and remain legislative monuments to what policymakers can achieve when they truly focus on the needs of their constituents.” 

Among the Medicare changes since then is the Jimmo v. Sebelius settlement of January 2013, which advocates still must cite to help beneficiaries. This settlement agreement addresses certain language on how Medicare covers skilled nursing care, such as in the rehabilitation wings of nursing homes, and skilled therapy services, including home health and outpatient therapy. 

As the Centers for Medicare and Medicaid Services (CMS) notes on its webpage, some health care providers may not be familiar with the settlement and may “erroneously” believe that the “Medicare program covers nursing and therapy services under these benefits only when a beneficiary is expected to improve.” 

Instead, provided that all other coverage criteria are met, CMS says that skilled nursing services would be covered if they are “necessary to maintain the patient’s current condition or prevent or slow further deterioration.” The Medicare beneficiary must require skilled care to safely and effectively address particular care needs.

For skilled therapy services, an individualized assessment of the person’s clinical condition must demonstrate that the “specialized judgment, knowledge and skill of a qualified therapist” are needed for a safe and effective program to, again, maintain the person’s current condition or prevent or slow further deterioration.

In other words, as stated in a CMS Jimmo Fact Sheet, “coverage cannot be denied based on the absence of potential for improvement or restoration.”

CMA notes that despite the Jimmo settlement, “Coverage for medically necessary services to which people are entitled under Medicare law remain difficult to obtain, especially for people with longer-term, chronic and debilitating conditions,” and gives home health care as an example.

New stimulus program begins for Farmers
Market

Starting with the July 11 Farmers Market in Pagosa Springs, SJBAAA is offering a new program that provides coupons for a limited number of older adult and caregiving shoppers who prefer to purchase local fresh produce. To apply, please contact Debra Herrera at 403-2164. The coupons will be available for 10 people in the beginning, and the program will continue if successful. The 10 people each will receive $50 in $5 coupons for the market.

The funds for the coupons come from the federal CARES Act, which was passed to help stimulate the economy and give support during the COVID-19 pandemic, so the coupons expire by Oct. 31.

The approved coupon users must follow the market’s entrance and social distancing requirements of keeping 6 feet apart and wearing a face covering. Anyone with preexisting health conditions due to oxygen limitations is exempt, but should let Herrera know. Those who have been accepted will be on a list; they must stop at the Farmers Market booth and mention that they are checking in for the SJBAAA CARES Act program. 

The market is open from 9 a.m. to 1 p.m. and is located on the south side of U.S. 160 at the east end of town within the East Side Market. The intended final Farmers Market date is Sept. 26.

This program is also offered to residents of Montezuma County and will be implemented soon in the region’s other counties.

SJBAAA offers resources for people age 60 and older or on Medicare. For further information, please call or text 403-2165 or send an email to leadombudsman@sjbaaa.org.