The Center for Medicare Advocacy and The Centers for Medicare and Medicaid Services (CMS) have agreed to settle in a nationwide class action case which challenged the “improvement standard” utilized when defining what services are considered “skilled” care, and therefore covered by a patient’s Medicare benefits. This settlement does not make any change to the existing law; however, it qualifies the definition of “skilled” to include those patients whose condition would deteriorate if the services of a professional, such as a nurse of licensed therapist, were no longer being provided. This clarification in the law applies to care being provided in the skilled nursing facility, at home via home healthcare services and to those receiving outpatient care.

If the judge approves the proposed agreement, a process that will likely take several months, the Medicare Benefit Policy Manual will be revised to reflect this qualification of coverage being dependent upon the beneficiary’s improvement. Medicare coverage will include services if they are needed to “maintain the patient’s current condition or prevent or slow further deterioration.” This prior limitation of improvement left many beneficiaries without the care they need to maintain their current condition because they simply could not afford these services on their limited, fixed incomes.

If you are denied coverage by a Medicare provider, it is important to ensure it is not on the basis of this incorrect definition of “skilled” care. For more information, you can read the exclusive article in the New York Times: