In March we posted a blog article informing readers about the Jimmo v. Sebelius settlement. Our article stated, “(t)he Jimmo agreement settles once and for all that Medicare coverage is available for skilled services to maintain an individual’s condition. Under the maintenance coverage standard articulated in the Jimmo Settlement, the determining issue regarding Medicare coverage is whether the skilled services of a health care professional are needed, not whether the Medicare beneficiary will “improve.” According to the Center for Medicare Advocacy, for decades, Medicare beneficiaries particularly those with long-term or debilitating conditions and those who need rehabilitation services have been denied necessary care based on the “Improvement Standard”. This illegal practice has resulted in Medicare coverage for vital care being denied to thousands of individuals on the grounds that their condition was stable, chronic, not improving, or that the necessary services were for “maintenance only.” The use of this illegal standard has had a particularly devastating effect on patients with chronic conditions such as Multiple Sclerosis, Alzheimer’s disease, ALS, Parkinson’s disease and paralysis. Now, Medicare can be available for therapy that is needed to maintain the person’s condition or to prevent further deterioration. It is not always necessary for the individual’s underlying condition to improve to continue to qualify for Medicare coverage!”
We are following up on this topic to inform readers that the Center for Medicare Advocacy (CMA) has recently provided an update about the settlement. In their update, the CMA made it clear that Medicare coverage of skilled nursing care as decided in the settlement is effective now. These means that those who meet all other Medicare criteria and are in need of skilled maintenance care should currently be covered by Medicare. The CMA encourages anyone who has been denied coverage to appeal the decision.
The Centers for Medicare & Medicaid Services (CMS) are currently working on revising their policies, guidelines and instructions to reflect Jimmo v. Sebelius settlement. Currently they have issued a Fact Sheet (http://www.medicareadvocacy.org/wp-content/uploads/2013/04/Jimmo-FactSheet.pdf) which outlines the settlement.
To read the entire update from the Center for Medicare Advocacy, including further information regarding making an appeal, please click the following: http://www.medicareadvocacy.org/medicare-info/improvement-standard/#.UpykK53CFmI.email
To view our original article posted in March of 2013 please click the following:http://newyorkelderlawblog.com/2013/03/14/the-improvement-standard-myth-and-skilled-nursing-care/