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Plaintiffs of Jimmo v. Sebelius Return to Court to Urge Enforcement and End Medicare “Improvement Standard”

August 19, 2016

On March 1, 2016 the Center for Medicare Advocacy and Vermont Legal Aid filed a Motion for Resolution of Non-Compliance with the Settlement Agreement in the landmark case, Jimmo v. Sebelius. The filing comes after three years of urging the Centers for Medicare & Medicaid Services (CMS) to fulfill its obligation to end continued application of an “Iimprovement standard” by Medicare providers, contractors and adjudicators resulting in denials of Medicare coverage for skilled maintenance nursing and therapy.
 
Jimmo was brought on behalf of a nationwide class of Medicare beneficiaries who were denied coverage and access to care because they did not show sufficient potential for “improvement.” This long-practiced standard contradicts Medicare law. The Jimmo Settlement leaves no doubt that under the law and related regulations and policies, it is not necessary to improve in order to obtain Medicare coverage for skilled services. Medicare is available for skilled nursing and therapy to maintain an individual's condition or slow deterioration. If truly implemented and enforced, the settlement should improve access to skilled maintenance nursing and therapy for thousands of older adults and people with disabilities whose Medicare coverage for skilled care is denied or terminated because their conditions are “chronic,” “not improving,” “plateaued” or “stable.”

The lawsuit was brought in United States District Court in Burlington, Vermont by seven individual plaintiffs from Vermont, Connecticut, Rhode Island, Maine and Pennsylvania and seven national organizational plaintiffs: National Multiple Sclerosis Society, the National Committee to Preserve Social Security and Medicare, Parkinson’s Action Network, Paralyzed Veterans of America, the American Academy of Physical Medicine and Rehabilitation, the United Cerebral Palsy Association and the Alzheimer’s Association.

The Center for Medicare Advocacy encourages people to appeal if they are told Medicare coverage is not available for skilled maintenance nursing or therapy because they are not improving. There is a great deal of information and self-help material on the Center’s website, www.medicareadvocacy.org, where beneficiaries can also obtain information with key provisions from the revised Medicare Manuals to show their health care providers.

UPDATE: On August 18th an opinion was released by in the “improvement standard” case. The Order requires CMS to remedy the Educational Campaign, which was a cornerstone of the Settlement Agreement, by “direct[ing] the Secretary [of Health and Human Services] to propose corrective action for Plaintiffs’ consideration within forty-five days of this Order.”  The goal continues to be to end the practice of denying coverage to tens of thousands of Medicare beneficiaries by replacing the illegal “Improvement Standard” with a maintenance coverage standard. The National MS Society Director of Health Policy, Kim Calder, is gratified that CMS will provide more education. “Among the reasons the National Multiple Sclerosis Society is a Jimmo plaintiff and applauded the Settlement was the promise that Medicare would provide a nationwide education campaign so Medicare’s own administrators, health care professionals and the public would know that continued ‘improvement’ is not a requirement for coverage and payment,” said Calder. “Rehabilitation therapy is an integral part of MS treatment because it helps prevent declines in walking, moving, speaking and optimal functioning.  Denying patients access to these treatments can lead to worsening disability, lack of independence and more expensive health care needs.”

Click here for more information from the National MS Society about Medicare

About Multiple Sclerosis

Multiple sclerosis is an unpredictable, often disabling disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body. Symptoms range from numbness and tingling to blindness and paralysis. The progress, severity and specific symptoms of MS in any one person cannot yet be predicted, but advances in research and treatment are leading to better understanding and moving us closer to a world free of MS. Most people with MS are diagnosed between the ages of 20 and 50, with at least two to three times more women than men being diagnosed with the disease. MS affects more than 2.3 million people worldwide.

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