'Improvement standard' lives on, Medicare refuses to cover Jimmo herself

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Judith A. Stein, founder of the Center for Medicare Advocacy
Judith A. Stein, founder of the Center for Medicare Advocacy

Medicare officials continue to cite an “improvement standard” as a reason for withholding benefits from Glenda Jimmo, whose 2012 legal victory was supposed to end this type of denial, Kaiser Health News reported Monday. The situation shows why both beneficiaries and providers are confused about current policy, and why some nursing homes continue to expect business-as-usual, an expert told McKnight's.

Longstanding Medicare practice was to deny claims for services meant to maintain a person's condition rather than improve it. Jimmo, who is blind and has a partially amputated foot, became the lead plaintiff in a class-action lawsuit challenging this status quo. The federal government ultimately acknowledged that no “improvement standard” ever actually existed, and it gave beneficiaries a chance to appeal relevant claim denials.

Jimmo was among the first to file an appeal, but it was rejected in April, according to KHN reporter Susan Jaffe. Judges on the Medicare Appeals Council said she didn't qualify for home healthcare intended only to maintain her condition.

The decision perplexes Judith Stein, executive director of the Center for Medicare Advocacy, which filed the original Jimmo class action. Under the settlement terms, a person generally should be eligible for skilled nursing, home health and therapy coverage even if he or she is not improving, Stein told Jaffe. Stein previously has noted that changes are not being swiftly and smoothly implemented.

“We are unfortunately finding providers are still reluctant to provide care because they are so accustomed to Medicare denials based on a need for improvement,” Stein told Jaffe.

Nursing homes are among the reluctant providers, Stein specified to McKnight's.

The Centers for Medicare & Medicaid Services has updated manuals and issued some educational materials about the implications of Jimmo. But as confusion persists, Jimmo herself is once again suing the government, seeking to ensure that the class action settlement is honored.