Judith Stein
Judith Stein

You may have heard the news in October that there is a proposed settlement agreement in the Medicare Improvement Standard case (Jimmo v. Sebelius, No. 5:11-cv-00017 (D.Vt.)) – a resolution more than a year and a half in the making. As a reminder, the Improvement Standard is a long practiced but illegal “rule of thumb” by which Medicare beneficiaries are denied coverage for skilled services because they are not deemed to be ‘improving.’

This harmful practice led to thousands of Medicare beneficiaries being denied coverage. Jane’s husband, for example, a U.S. Navy World War II veteran who joined the service after Pearl Harbor and fought in the Battle of Iwo Jima, suffers from Parkinson’s disease. He recently fell in his home. After he was released from the hospital, he was transferred to a skilled nursing facility. After some time, his Medicare coverage was terminated because he was not ‘improving.’

How will the proposed settlement help Jane, her husband and others across the country? And how does it affect you?

Next steps:

Under the proposed settlement, a nationwide class of beneficiaries will be certified, numerous parts of the Medicare Benefit Policy Manual will be rewritten, and the Centers for Medicare & Medicaid Services (CMS) will carry out an educational campaign for providers, Medicare contractors and adjudicators. The revised CMS manual language will clarify that Medicare coverage is available for maintenance services when skilled personnel are required to perform or supervise the nursing or therapy safely and effectively. Once the settlement is formally approved (expected in early 2013), CMS has one year to update the Medicare Manual, get the changes into writing and complete the education campaign.

In addition, many class members will have an opportunity to have their previously denied claims reviewed under the revised Medicare standards. (Basically, claims denied because the individual was not improving since the lawsuit’s filing on January 18, 2011 has a right to an appeal.) Plaintiffs’ attorneys will monitor and, if necessary, enforce the provisions of the agreement.

Your role:

Being in the long-term care industry, you are a crucial component of ending the Improvement Standard practice. Together, we can ensure that beneficiaries get the coverage they’re entitled to that can enhance their well-being and maintain their quality of life. Here are a few things you can do:

  • Inform beneficiaries you work with about the Jimmo Settlement and its implications. There are self help packets available online, as well as FAQs and other information about the case at www.medicareadvocacy.org.
  • Spread the word to patients and their families, as well as your colleagues. Informed consumers are protected consumer!
  • Send information about the case to friends and colleagues.
  • Stay tuned for additional developments.

Mrs. Jimmo, the lead plaintiff in the case, is blind and has had her right leg amputated due to complications from diabetes. She requires a wheelchair, and receives multiple home health care visits per week for various treatments for her complex condition. However, Medicare denied coverage for these vital quality of life services, saying that she was unlikely to improve. By eliminating the Improvement Standard, beneficiaries like Mrs. Jimmo and others like her will get the Medicare coverage and vital health care they need and deserve.

Judith Stein is the executive director of the Center for Medicare Advocacy.