My dad, a 90 year old stroke survivor who lost the use of the left side of his body, was discharged from Med A therapies at his SNF in July 2022. The Med A therapies at this facility were substandard - speech and occupational only lasted about 2 weeks, physical therapy lasted the full 85 days. However the facility is close to home which makes it super convenient. My dad still has massive occupational deficits (he can't use his left arm or hand) and speech/swallowing difficulties that put him at great risk for pneumonia.
Since his discharge from Med A, my dad was picked up on Med B (for physical therapy only) and then subsequently discharged a couple weeks later to what was supposed to be a functional restorative nursing program where he would participate in daily walking activities. This was the "off ramp" that the SNF usually offers. Unfortunately he was never picked up in the walking program. After speaking to one of the CNAs in the restorative walking program, she spilled the beans - my dad was never picked up for the restorative walking program because they were to short staffed to take on patients who required "max assist". Her own word were "nobody wants to work in healthcare".
The SNF clearly can't prevent my dad's decline with Med B/restorative, so why the hell won't they pick him up for Med A therapies once again using the 3-day hospital waiver? After being told by the director of therapy at this SNF that Medicare "cannot be used to prevent decline", I handed him the Jimmo Settlement FAQ sheet from CMS.gov (https://www.cms.gov/Center/Special-Topic/Jimmo-Center) and asked him why he was so misinformed about what Medicare will pay for. I also asked him if he ever heard of the Jimmo settlement, to which he replied he had not.
---How does the director of therapy at a modern SNF not know about the Jimmo Settlement? Did he actually not know about the Jimmo Settlement or did corporate just tell him to play dumb when talking to me?
---How do I get the SNF to acknowledge the new Jimmo Settlement guidelines for Medicare beneficiaries, specifically their ability to access Medicare benefits to prevent decline?
---What carrot or stick do I have to use to get this SNF to get my dad picked up on Med A once again?
fwiw for those not familiar with Jimmo, it’s Jimmo V. Sibelius (Kathryn Sibelius who was head of DHHS in 2013 when this class action was filed). Jimmo, the plaintiff, was a diabetic, legally bind amputee on MediCARE. She had been receiving inhome care & OPT (out patient therapy & considered skilled care done by a PT, OT, ST) paid by Medicare. MediCARE had covered these services but stopped as Medicare applied “Improvement Standards” for determining as to whether Medicare would pay; & Jimmo did not meet improvement.
Jimmo was lead plaintiff, but others in the class action were mainly those with MS (multiple sclerosis) & ALS (Lou Gehrig disease). I’m familiar w Jimmo as my cousin had secondary polio and was on inhome & OPT, & the agency he used sent out notifications as to Jimmo as it plodded along legal path as to what it could mean for their clients.
Jimmo settlement requires Medicare to look at certain standard BEYOND “Improvement” alone for claim determination; & those who can benefit for skilled services for maintenance or to prevent or slow decline or deterioration, then Medicare beneficiaries are entitled to coverage.
imho I think the issue for ,your dad will be is there is no “maintenance” for him to stay at. Continuing rehab or restarting rehab won’t change his prognosis or slow decline of his diagnosis. It’s not a Jimmo thing. Jimmo has been around almost a decade now, facilities and agencies have the settlement criteria in their billing system. It’s not something that the therapist needs to deal with, as they look at the ICD-10 codes and then the details after a session and it’s all entered into Medicare. & pretty much in real time Medicare will evaluate if services continue.
You as his POA can file an appeal with Medicare; depending on where he is in his time line it will be a redetermination appeal (this one more about coding or incorrect evaluation) or a reconsideration letter (these are kinda getting filed due to Covid services not provided in a timely manner)
Jimmo seems to be used best for:
1. Have a preexisting condition like MS, ALS, Parkinson’s, amputation, paralysis as they need and can benefit from “maintenance” or other therapy to “slow or prevent decline”. Like for my cousin, secondary polio had paralysis issues, so PT as maintenance slowed muscle loss.
2. getting skilled services in their home or in outpatient center
3. if in a facility, get therapy to “slow decline of current capabilities”. NH routinely have PTs do “gait training” with residents and MediCARE pays for this as its slows decline. & they have OTs do exercises with their hands & arms to keep residents ability to clench flatware or hold things so it slows decline & Medicare pays for this. This is all covered by Medicare as part of the 2013 Jimmo settlement.
Not to be harsh, but I think the issue will be that your dad does not have
“current capabilities” to preserve and his hospitalization discharge, rehab & therapist notes show that is the case and why he has been denied.
I know it’s all quite overwhelming to deal with all this. Please please pls try to go over with the SNF DON (director of nursing) as to his latest needs assessment so that you have a better idea of what his situation is and what level of care he requires. If hospice is suggested, that is totally a MediCARE benefit. Hospice is done via a consult and slightly different than a needs assessment but intertwined.
Hospice as it’s MediCARE, is self-directed. So in theory, dad can pick which hospice group he wants. Most facilities have 3-4 hospice groups that come into their facility. You as your dads POA can choose. My mom was on hospice 18 l…o..n..g months and I switched out hospice within first 6 weeks. The 2nd hospice group was a better “fit”. Hospice is self directed, you can do this. Not exactly simple, but doable. Good luck in all this.
Are you in Illinois? https://www.bcbsil.com/bcchp/resources/the-illinois-long-term-care-ombudsman-program
Send a copy of Jimmo to the exec. director of the facility and the corporate office if they are part of a larger organization.
Call your local representative's office and ask for their staff member who works on elder affairs.
-I sent a copy of Jimmy to the administrator of my SNF today, but her email auto replied that she will be out of the office until Monday.
-My state representative? Chances are if I talk to anyone from my state they will say it is a Medicare problem and to call Medicare.