• Medicare’s “Improvement Standard” Deemed Illegal: Benefits can no longer be denied to patients judged as having lack of restoration potential

By Carol Barton

The U.S. District Court of Vermont, on January 24, 2013, approved a settlement in the case of  Jimmo v Sebelius which has led to a significant change in Medicare policy that ensures beneficiaries receive the full benefits to which they are entitled. Prior to the settlement, Medicare contractors inappropriately denied coverage for patients based on the Medicare “Improvement Standard.”

Glenda Jimmo lent her name to this class action lawsuit. She had been blind since age 19 and, at age 76, was confined to a wheelchair due to a disabling condition that included a below-the- knee amputation as a result of diabetes. Glenda required skilled nursing in her home for wound care and to manage her condition. Medicare refused to pay for those services because she did not “demonstrate medical potential to improve” leaving her, and other Medicare recipients, paying for care themselves or going without needed care.

Under the settlement agreement, the U.S. Department of Health and Human Services agreed to relax Medicare’s requirements for coverage of skilled nursing and therapy service in the home or in an institutional setting. Medicare can no longer deny care to patients on the grounds that their condition is stable, chronic or not improving. The Centers for Medicare & Medicare Services (CMS) is mandated to make revisions to the Medicare Benefit Policy Manual as well as to other policies and guidelines. Additionally, CMS must develop and implement a nationwide education campaign for all who make Medicare determinations that ensures beneficiaries with chronic conditions are not denied coverage of critical services simply because their underlying conditions will not improve.

It is important to note that although CMS has until January 2014 to complete the changes to its manuals and to implement its educational campaign – the law applies now. For more information on the ruling you may visit www.medicareadvocacy.org.

There have been instances where some claims continue to be denied. You cannot assume that healthcare professionals or Medicare contractors know the rules. If you know of a situation where a claim is denied or if you need clarification about the ruling, call an elder law attorney for help.

Bookmark and Share