The Settlement Agreement in the Medicare Improvement Standard case, Jimmo v. Sebelius, was approved today by Chief Judge Christina Reiss at the conclusion of a scheduled fairness hearing, marking a critical step forward for thousands of beneficiaries nationwide. For decades, Medicare beneficiaries – particularly those with long-term or degenerative conditions and those who need rehabilitation services – have been denied necessary care based on the Improvement Standard: on the grounds that their condition was stable, chronic or not improving, or that the necessary rehabilitative services were for "maintenance only."
The lawsuit, Jimmo v. Sebelius, was brought on named defendant, Secretary of Health and Human Services Kathleen Sebelius, by plaintiffs: a nationwide class of Medicare beneficiaries including six individual beneficiaries (including Glenda Jimmo, of Lincoln, Vt.) and seven national organizations – including the National MS Society – to challenge the use of the illegal Improvement Standard. “This moment is a culmination of two years of hard work, in conjunction with partners and advocates, to ensure that those who need health services covered under the Medicare law are not denied based on an illegal, outdated rule of thumb,” said Gill Deford, Litigation Director of the Center for Medicare Advocacy.
“The National MS Society is pleased at the case’s outcome, and sees it as a critical step forward for thousands of people with MS nationwide,” said Society President & CEO, Cyndi Zagieboylo. “We encourage providers and/or patients to appeal should they be denied Medicare for skilled maintenance nursing or therapy because they are ‘not improving.’”
With the settlement officially approved, the Centers for Medicare & Medicaid Services (CMS) is tasked with revising its Medicare Benefit Policy Manual and numerous other policies, guidelines and instructions to ensure that Medicare coverage is available for skilled maintenance services in the home health, nursing home and outpatients settings. CMS must also develop and implement a nationwide education campaign for all who make Medicare determinations to ensure that beneficiaries with chronic conditions are not denied coverage for critical services because their underlying conditions will not improve.
The Settlement Agreement standards for Medicare coverage of skilled maintenance services apply now – while CMS works on policy revisions and its education campaign. “We’ve been hearing from beneficiaries who are still being denied Medicare coverage based on an Improvement Standard,” said Judith Stein, Executive Director, Center for Medicare Advocacy. “Coverage should be available now for people who need skilled maintenance care and meet any other qualifying Medicare criteria.”
For people needing assistance with appeals, the Center for Medicare Advocacy has self-help materials available on its website, www.medicareadvocacy.org. This information can help individuals understand proper coverage rules and learn how to contest Medicare denials for outpatient, home health, or skilled nursing facility care. Or contact the National MS Society at 1-800-344-4867. The Society also offers a guide to aid in the dialogue between MS clinicians and health plans when disputes over coverage arise.
“It is exciting to know that by this time next year, Medicare policies will clearly state that coverage for skilled maintenance nursing and therapy is available, and that a beneficiary’s access to coverage does not depend on the potential for improvement, but rather on the need for skilled care,” continued Stein.
Although the Settlement Agreement rejects the Improvement Standard, it does not guarantee coverage. The case was not intended to – nor could it – eliminate the need to prove that care is medically reasonable and necessary.
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View the Notice of Settlement
About the Center for Medicare Advocacy
The Center for Medicare Advocacy, Inc., established in 1986, is a national nonprofit, nonpartisan organization that provides education, advocacy and legal assistance to help older people and people with disabilities obtain fair access to Medicare and necessary health care. The organization focuses on the needs of Medicare beneficiaries, people with chronic conditions, and those in need of long-term care. The organization is involved in writing, education, and advocacy activities of importance to Medicare beneficiaries nationwide. www.medicareadvocacy.org