Re: [Beneficiary’s Name], Medicare No. [XXXXX]
To Whom It May Concern:
I am writing on behalf of my client, [Full Name], to request an expedited reconsideration. The skilled nursing facility (SNF) terminated Mr./Ms. [Last Name]’s Medicare coverage on [Date]. The SNF told Mr./Ms. [Last Name] that his/her Medicare coverage was ending because he/she no longer needed skilled nursing and/or therapy due to a lack of improvement. However, Mr./Ms. [Name]’s medical record indicates, and his/her primary care professionals agree, that SNF care is still medically necessary. Furthermore, terminating Medicare coverage solely on the basis of a beneficiary’s potential for improvement is a violation of the settlement agreement in the nationwide class-action lawsuit Jimmo v. Sebelius, No. 5:11-CV-17 (D. Vt. 2013). In fact, coverage is equally available for skilled nursing and/or therapy services that maintain, slow, or prevent the further decline of a beneficiary’s condition. Therefore, Mr./Ms. [Last Name] respectfully asks that Medicare coverage of his/her SNF stay be reinstated without delay to prevent an unnecessary decline in his/her condition.
[Background. How old is your client? What is the injury or illness? What was your client’s health and life like before the injury or illness? What caused your client’s injury or illness? When did your client go to the hospital? What services did your client receive at the hospital? Why did the hospital order the skilled nursing and/or therapy? Why is the skilled care medically necessary to treat your client’s condition?]
[Care while at the SNF. When did your client go to the SNF? For how many days or weeks did he/she receive daily skilled nursing and/or therapy? What skilled services are in your client’s order and care plan? What are your client’s goals? What services did your client actually receive and how often? How did your client respond to the skilled services? Did your client’s condition improve? Is it the case that your client is improving but his/her improvement is slower than what the facility expects? Did your client benefit from the maintenance program? What does your client’s medical record say? Have your client’s friends and/or family seen any improvements? Describe and detail those improvements or benefits.]
[Need for Ongoing Skilled Care. Why does your client still need skilled nursing and/or therapy? How will skilled care allow your client to reach his/her goals? Why does your client need the specialized judgment, knowledge, and skills of a qualified therapist? Why would such care provided by non-skilled people be unsafe and ineffective in treating your client’s condition?]
[Support from Primary Care Professionals. Does your client’s physician(s) believe that SNF care is still medically necessary? What about other care professionals? Is there any language from letters of support that could be quoted here?]
If Mr./Ms. [Last Name] is not improving, the Jimmo Settlement required the Centers for Medicare & Medicaid Services (CMS) to confirm that Medicare coverage is determined by a beneficiary’s need for skilled care, not on a beneficiary’s potential for improvement. Medicare Benefit Policy Manual (MBPM), Ch. 8, § 30. Medicare policy now clearly states that “[s]killed care may be necessary to improve a patient’s condition, to maintain a patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.” MBPM, Ch. 8, §§ 30.2, 30.3. The Jimmo Settlement means that Mr./Ms. [Last Name] should not be denied coverage solely on the basis of an erroneous “Improvement Standard.”
Upon deciding that Mr./Ms. [Last Name] no longer had the potential to improve, and rather than terminating his/her Medicare-covered skilled care, the SNF should have completed a new assessment and revised Mr./Ms. [Last Name]’s treatment goals to establish a maintenance program. MBPM, Ch. 8, 220.127.116.11. CMS has explicitly confirmed that such maintenance programs are covered by Medicare, stating, for skilled therapy, that “services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of a safe and effective maintenance program.” MBPM, Ch. 8, § 18.104.22.168(E). Allowing Mr./Ms. [Last Name] to resume his/her Medicare-coverage would allow the SNF time to correct this mistake and develop a maintenance plan of care.
Mr./Ms. [Last Name]’s medical record and personal experience show that he/she has [made improvements/benefited from skilled maintenance care] in the short time he/she has been at the SNF. Based on his/her ongoing need for medically necessary skilled therapy for safe and effective treatment, and the Jimmo Settlement, the decision to terminate Medicare-coverage for Mr./Ms. [Last Name] should be reversed. Deciding otherwise, as Mr./Ms. [Last Name]’s primary care professionals have stated, may result in his/her condition declining, resulting in additional health care costs to both Mr./Ms. [Last Name] and the Medicare program.
Admitted to practice law in [State]