Jimmo implementation is troubled, long-term care expert says

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Skilled nursing providers remain confused about Medicare changes related to the Jimmo v. Sebelius legal settlement, and many beneficiaries are not aware that their therapy might now be eligible for coverage, according to prominent long-term care expert Judith Stein. Stein is an attorney and director of the Center for Medicare Advocacy, which along with Vermont Legal Aid filed the Jimmo case.

“There's still a great deal of education that healthcare providers need to get on this,” Stein told Reuters columnist Mark Miller, about the implications of Jimmo. “Many of them just aren't aware of what they need to do to proceed.”

Under the settlement that was finalized in January 2013, the Centers for Medicare & Medicaid Services was obligated to distribute educational materials to skilled nursing providers. CMS has since posted online resources and updated the Medicare manual to reflect that, per the settlement, Medicare will reimburse for medically necessary skilled care, even if the goal simply is to maintain a patient's condition. Prior to Jimmo, Medicare operated under a de facto “improvement standard,” under which skilled care only was covered if it could lead to a beneficiary's condition improving.

Not only is provider education falling short, but many beneficiaries do not know about the changes or still are having problems getting coverage for care, Stein told Miller. CMS is not legally required to educate consumers about the Jimmo decision.

Providing one example, Miller reported on 78-year-old Robert Klaiber. He and his wife have been drawing on their retirement savings to pay for therapeutic massages he receives for Parkinson's disease, and through happenstance they learned about the settlement. While it appears the massages now should be covered under Medicare, the provider is uncertain and so far the situation is unresolved, Miller wrote in a column published Tuesday.

Overall, the post-Jimmo era is off to a “rocky start,” he concluded. 

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