Jimmo succeeds in getting Medicare coverage, two years after landmark case ended

Share this content:

Glenda Jimmo has reached a settlement with the federal government and will finally receive Medicare coverage for claims that were denied in 2007, which led her to file a class-action lawsuit over the so-called “improvement standard.”

Jimmo's class action came to an end in 2012, with the government acknowledging that Medicare should not reject claims simply because they are for services to maintain rather than improve a person's condition. Jimmo, who is blind and has a partially amputated foot, then filed an appeal to have her previously rejected maintenance therapy claims reconsidered.

As reported earlier this week, a Medicare Appeals Council rejected Jimmo's appeal, again citing the improvement standard. Legal experts said the decision was confusing, given that this rationale was debunked under the 2012 class action settlement. Jimmo filed a federal lawsuit to challenge the council's decision, which was settled Wednesday.

The Appeals Council decision is “completely vacated” under the settlement, and Medicare will reimburse Jimmo's provider — Addison County Home Health and Hospice — the full disputed amount of about $11,500. The Department of Health and Human Services also will pay Jimmo's legal fees, totaling $4,400.

"This settlement should send the message that denying Medicare coverage for a chronic condition is wrong,” stated Jimmo's attorney, Michael Benvenuto, director of Vermont Legal Aid's Medicare Project.

The settlement may help clarify that the improvement standard is no longer in effect. Changes have been slow following the 2012 resolution of the class action suit. Nursing homes and other providers continue to be hesitant about providing maintenance therapy, for fear that it will not be reimbursed, Center for Medicare Advocacy Executive Director Judith Stein told McKnight's this week.

The settlement indicates that Jimmo might receive Medicare coverage for similar maintenance care going forward, Stein noted in a press release issued Thursday.