Experts argue court didn't go far enough in new 'Jimmo' case mandate

Cynthia Morton
Cynthia Morton

While pleased with a court decision mandating that the Centers for Medicare & Medicaid Services should do better in explaining maintenance coverage under the landmark Jimmo case, leading long-term care experts said more can be done.

U.S. District Court Chief Judge Christina Reiss wrote in an opinion released Thursday that Glenda Jimmo and plaintiffs had proved that HHS Secretary Sylvia Burwell had “failed to fulfill the letter and spirit of the Settlement Agreement with respect to at least one essential component of the Educational Campaign.” The settlement in question was approved in January 2013.

Although experts said Friday that the decision represented progress, they also felt it came up short.

“I am disappointed that the court didn't order CMS to better clarify the benefit manual that governs the policy,” said Cynthia K. Morton, executive vice president at the National Association for the Support of Long Term Care.

“Unclear benefit manuals can lead to patients' services being denied and then providers have to expend resources to appeal those denials. CMS's education campaign should include the Medicare administrative contractors so that they are better informed as to what this case is all about and that is that patients can receive therapy to maintain function,” she said.

The CMS education effort “has not been adequate, timely or complete,” said Mike Cheek, Senior Vice President of Finance Policy and Legal Affairs at the American Health Care Association

“We applaud the court's directive for CMS to remedy this, which will help beneficiaries gain access to the vital skilled services to maintain their health, level of independence and quality of life,” he said.

The plaintiffs had submitted several coverage decisions that they said reflected uncertainty over the maintenance coverage standard and application of an improvement standard, according to court records. It reflects how there is “significant confusion for providers and patients regarding when skilled services are needed, not for improvement, but for maintenance in chronic conditions,” said LeadingAge Senior Vice President for Public Policy and Health Services Cheryl Phillips, M.D.

“We are hoping that this ruling will lead to much broader education, and improved access to needed skilled services for those who need them,” she said.