Medicare Beneficiaries Across the Country Still Denied Needed Coverage Due to Illegal Use of Improvement Standard

Content provided by The Center for Medicare Advocacy, Inc.

On March 1, 2016, The Center for Medicare Advocacy and Vermont Legal Aid filed a Motion for Resolution of Non-Compliance with the Settlement Agreement in the landmark case, Jimmo v. Sebelius.

The filing comes after three years of urging the Centers for Medicare & Medicaid Services (CMS) to fulfill its obligation to end continued application of an “Improvement Standard” by Medicare providers, contractors and adjudicators to deny Medicare coverage for skilled maintenance nursing and therapy.

Jimmo was brought on behalf of a nationwide class of Medicare beneficiaries who were denied coverage and access to care because they did not show sufficient potential for “improvement.”

This long-practiced standard contradicts Medicare law.

The Jimmo Settlement leaves no doubt that, under the law and related regulations and policies, it is not necessary to “improve” in order to obtain Medicare coverage for skilled services.

Medicare is available for skilled nursing and therapy to maintain an individual’s condition or slow deterioration.

If truly implemented and enforced, the Settlement should improve access to skilled maintenance nursing and therapy for thousands of older adults and people with disabilities whose Medicare coverage for skilled care is denied or terminated because their conditions are “chronic,” “not improving,” “plateaued” or “stable.”

Unfortunately, providers and contractors continue to illegally deny Medicare coverage and care based on an “Improvement Standard,” resulting in beneficiaries, nationwide, failing to obtain needed skilled nursing and therapy coverage.

This continued loss of skilled care, based on an “improvement” requirement, is occurring despite the assertion by CMS that it has completed the education campaign required by the Settlement.

That campaign, however, has clearly failed to educate key components of the provider community and Medicare decision-making system.

The Center for Medicare Advocacy, Inc. “Jimmo v. Sebelius Plaintiffs Return to Court to Urge Enforcement.” CMA. 1 Mar. 2016. Web. 8 Mar. 2016.