A nationwide class of Medicare beneficiaries and seven organizations reached a settlement with the Department of Health and Human Services (HHS) and Department of Justice (DOJ) in the case ofJimmo v. Sebelius. The settlement stipulates that skilled services to maintain an individual’s condition or prevent or slow their decline are covered by Medicare and that the so-called “improvement standard” that Medicare had been employing is illegal.
Under the text of the settlement agreement, Medicare coverage hinges on whether the skilled services of a health care professional are medically necessary, not whether the beneficiary will “Improve.” Medicare can no longer deny care to patients on the grounds that their condition is stable, chronic, or not improving. The Centers for Medicare & Medicaid Services (CMS) must now make revisions to the Medicare Benefit Policy Manual and numerous other policies, guidelines and instructions to ensure that Medicare coverage is available for skilled maintenance services in the home health, nursing home and outpatient settings. CMS must also develop and implement a nationwide education campaign for all who make Medicare determinations to ensure that beneficiaries with chronic conditions are not denied coverage for critical services because their underlying conditions will not improve.
AOTA will be working with both CMS and the Center for Medicare Advocacy during the revision process. For further information, please contact Regulatory Affairs at firstname.lastname@example.org.
AOTA first reported on the filing of the class action lawsuit in January 2011, and has been following the case throughout the process.
Improvement Standard Update: Glenda Jimmo Sues Medicare Again for Ongoing Denials (2014)
Medicare Policy Changed: No “Improvement Standard” Can Be Used to Deny Coverage (2013)
Medicare Will Not Be Able to Use “Improvement Standard” for Denying Therapy Coverage (2013)
Medicare Too Strict: Two Courts Limit the “Improvement Standard” in SNF, HH (2011)
Settlement Agreement Fact Sheet (CMS, April 2013)
MLN Matters Article: Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius (pdf)
Transmittal 179 (January 7, 2014)
Settlement Agreement (Filed October 16, 2012 and approved January 24, 2013)
Center for Medicare Advocacy, Inc. Summary of the Case and FAQs
Settlement Eases Rules for Some Medicare Patients (The New York Times, October 22, 2012)
A Humane Medicare Rule Change (The New York Times, October 23, 2012)
Jimmo, et al. v. Sebelius, No. 5:11-cv-17 (D.Vt.) (Filed January 18, 2011)