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Laws 2017, 6(4), 21; doi:10.3390/laws6040021

Disparities in Private Health Insurance Coverage of Skilled Care

UNLV William S. Boyd School of Law, Las Vegas, NV 89154, USA
Academic Editor: Elizabeth Pendo
Received: 5 September 2017 / Revised: 4 October 2017 / Accepted: 6 October 2017 / Published: 20 October 2017
(This article belongs to the Special Issue Health Care Law and the Rights of Individuals with Disabilities)
View Full-Text   |   Download PDF [195 KB, uploaded 20 October 2017]

Abstract

This article compares and contrasts public and private health insurance coverage of skilled medical rehabilitation, including cognitive rehabilitation, physical therapy, occupational therapy, speech-language pathology, and skilled nursing services (collectively, skilled care). As background, prior scholars writing in this area have focused on Medicare coverage of skilled care and have challenged coverage determinations limiting Medicare coverage to beneficiaries who are able to demonstrate improvement in their conditions within a specific period of time (the Improvement Standard). By and large, these scholars have applauded the settlement agreement approved on 24 January 2013, by the U.S. District Court for the District of Vermont in Jimmo v. Sebelius (Jimmo), as well as related motions, rulings, orders, government fact sheets, and Medicare program manual statements clarifying that Medicare covers skilled care that is necessary to prevent or slow a beneficiary’s deterioration or to maintain a beneficiary at his or her maximum practicable level of function even though no further improvement in the beneficiary’s condition is expected. Scholars who have focused on beneficiaries who have suffered severe brain injuries, in particular, have framed public insurance coverage of skilled brain rehabilitation as an important civil, disability, and educational right. Given that approximately two-thirds of Americans with health insurance are covered by private health insurance and that many private health plans continue to require their insureds to demonstrate improvement within a short period of time to obtain coverage of skilled care, scholarship assessing private health insurance coverage of skilled care is important but noticeably absent from the literature. This article responds to this gap by highlighting state benchmark plans’ and other private health plans’ continued use of the Improvement Standard in skilled care coverage decisions and identifying possible legal approaches for removing the Improvement Standard in private health insurance. This article also calls for scholars in health law, disability law, and insurance law, among other doctrinal areas, to evaluate the ethics and values associated with the continued use of the Improvement Standard in private health insurance. View Full-Text
Keywords: skilled care; Medicare; private health insurance; stigma; improvement; maintenance skilled care; Medicare; private health insurance; stigma; improvement; maintenance
This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. (CC BY 4.0).

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Tovino, S.A. Disparities in Private Health Insurance Coverage of Skilled Care. Laws 2017, 6, 21.

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