Vermont Legal Aid and the Center for Medicare Advocacy are pleased to announce the settlement of McKee v. Azar, a case that was brought in federal court to ensure proper coverage of home health care services for a Medicare beneficiary with multiple chronic conditions. Ms. McKee, a Vermont resident, required skilled nursing visits to assess and treat her serious medical conditions, which included difficulty breathing, digestive problems, and significant swelling in her legs with a continuing need for leg wound care.
Medicare denied coverage, concluding that her condition was “stable” and therefore did not require skilled care. This was erroneous under the standard clarified in the Jimmo v. Sebelius settlement. In her lawsuit, Ms. McKee challenged the notion that her supposedly “stable” condition meant that the care she received was not skilled. She argued that she was eligible for home health coverage based on skilled observation and assessment as well as patient education services. Ms. McKee was at risk for complications, and the knowledge and judgment of skilled nurses were key to identifying when she needed additional or modified care. In addition, Ms. McKee challenged Medicare’s failure to afford appropriate weight to the opinion of her treating physician about her need for skilled care.
Under the terms of a settlement agreement filed on July 21, 2020, Medicare agreed to pay Ms. McKee’s home health claim in full.
Advocates should continue to be alert for inappropriate denials of coverage based on lack of improvement or on “stability” – particularly for individuals with chronic conditions. Jimmo requires Medicare coverage determinations to be based on individuals’ need for skilled care, not on their potential for improvement or on their stability. Skilled nursing, or physical, occupational, or speech therapy may be required to maintain a person’s condition or to prevent or slow deterioration. For more information about Jimmo and the “Improvement Standard,” see the webpages of the Center for Medicare Advocacy and CMS.