Jimmo v. Sebelius Fact Sheet: Medicare Skilled Nursing Facility Coverage Does Not Require Improvement
In 2013, a federal district court approved a settlement agreement in the case of Jimmo v. Sebelius that confirmed Medicare coverage should be determined by a beneficiary’s need for skilled care, not the individual’s potential for improvement.
The Center for Medicare Advocacy (the Center) and Vermont Legal Aid brought this class action lawsuit against the Centers for Medicare and Medicaid Services (CMS) because Medicare beneficiaries were being denied skilled care coverage due to an erroneous “Improvement Standard”, which resulted in claims being denied if full recovery or medical improvement was not possible. In fact, coverage depends not on an individual’s restoration potential, but on whether skilled care is required.
The Jimmo settlement confirmed that coverage of skilled nursing or therapy is available to anyone who needs those services to maintain or slow deterioration – regardless of the underlying illness, disability, or injury. Unfortunately, eight years later, the Center is still hearing about problems related to the mythical “Improvement Standard”.
The Center created this Factsheet, with support from The John A. Hartford Foundation, to outline Medicare beneficiary rights when it comes to Medicare coverage in a skilled nursing facility.
In an interim final rule with comment, the Centers for Medicare & Medicaid Services (CMS) requires nursing facilities and intermediate care facilities for individuals with intellectual disabilities (1) to educate residents and their representatives and staff about vaccinations for COVID-19, (2) to offer residents and staff vaccinations, if available to the facility, and (3) to report vaccine information to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). CMS intends to post the information reported to CDC on its COVID-19 Nursing Home Data website, https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg. The rule goes into effect May 21, 2021; comments are due by July 12, 2021.
The Center for Medicare Advocacy has two recommendations.
- First, knowing that residents and families choosing a nursing home are likely to want to know about facility’s vaccination rates, the Center recommends that the nursing home section of Care Compare (the federal website for the public about nursing homes and other health care providers) include (1) a statement that information about vaccination rates in facilities is available on its COVID-19 Nursing Home Data website and (2) a link to the website.
- Second, the Center recommends that CMS impose specific civil money penalties when facilities fail to educate residents and staff about vaccinations and fail to offer vaccinations. At present, in a letter to state survey agencies describing the interim final rule, CMS reports that it will impose specific penalties only when facilities fail to report to CDC — $1,000 for the first occurrence, increased by $500 for repeated noncompliance.
Among other issues, CMS invites public comment on whether it should implement similar vaccination policies for other Medicare and Medicaid participating shared residences, such as assisted living and adult foster homes.
For further information and instructions on how to comment, see:
- 86 Fed. Reg. 26306 (May 13, 2021), https://www.govinfo.gov/content/pkg/FR-2021-05-13/pdf/2021-10122.pdf and
- CMS, “Interim Final Rule – COVID-19 Vaccine Immunization Requirements for Residents and Staff,” QSO-21-19-NH (May 11, 2021) (describing the interim final rule in a memorandum to state survey agencies), https://www.cms.gov/files/document/qso-21-19-nh.pdf
Developed in collaboration with Larry Coffee, DDS, the esteemed dentist who founded the Dental Lifeline Network, a national nonprofit organization that provides critical dental therapies to needy disabled, elderly, and medically fragile individuals through volunteer dentists, this series of fact sheets explains the interrelationship between oral health and major medical conditions, such as diabetes, heart disease and cancer.
Each fact sheet offers important oral health tips for persons living with these medical conditions, as well as their caregivers, advocates, and health care providers. While individual prevention and management of oral and dental disease are important in the context of certain underlying health problems, access to affordable dental coverage and care can be absolutely vital as well. This latter component is one that too many Medicare beneficiaries currently lack. We hope these fact sheets will serve to illustrate why the meaning of health care needs to include oral health care, and why oral health benefits should be added to Medicare.
- Fact Sheet – Dental Issues Related to Pulmonary Diseases