Contact: Ali Bers, Litigation Attorney, Center for Medicare Advocacy
(860) 456-7790, abers@medicareadvocacy.org
Michael Benvenuto, Project Director, Vermont Legal Aid, Inc.
(802) 343-0967, mbenvenuto@vtlegalaid.org
Burlington, VT: The Center for Medicare Advocacy and Vermont Legal Aid filed a class action lawsuit against Sylvia Mathews Burwell, the Secretary of Health and Human Services, to stop Medicare’s practice of repeatedly denying coverage for home health services for beneficiaries on the basis that they are allegedly not homebound, when Medicare has previously determined them to be homebound. (Ryan v. Burwell). The lawsuit was filed on December 19 in the United States District Court in Burlington, Vermont on behalf of two Vermont residents, Marcy Ryan and John Herbert, as a regional class action lawsuit covering New England and New York.
Under Medicare rules, home health services including skilled nursing and therapy services are only available to beneficiaries who are "homebound." This lawsuit does not challenge that underlying requirement. Rather, it seeks to stop Medicare’s practice of repeatedly denying coverage after a Medicare administrative judge has ruled that the beneficiary is homebound.
The plaintiffs, like many Medicare beneficiaries, are seriously disabled and use a wheelchair. Medicare administrative judges have found both of them to be homebound on several occasions when they appealed Medicare decisions and in each case, granted coverage for home health services. Even after the plaintiffs won the appeals and the judges ruled that they were homebound, the contractors that administer benefits for Medicare continue to deny the plaintiffs’ subsequent claims for services.
The practice of repeatedly denying claims for a beneficiary that has won previous appeals violates Medicare’s own policies.
"Medicare policies state that once plaintiffs have been found to be homebound by a Medicare judge, they should be presumed to be homebound for Medicare coverage, unless there is evidence that they have improved," explains Rachel Seelig, a staff attorney at Vermont Legal Aid. "It is wrong for Medicare to continually and repeatedly deny them coverage."
Gill Deford of the Center for Medicare Advocacy, co-counsel for the plaintiffs in this case and lead counsel in the case of Jimmo v. Sebelius, which led to the end of Medicare’s "Improvement Standard," saw parallels to Jimmo in the Ryan situation. "Once again, you have Medicare ignoring its own rules and requiring beneficiaries to slog through the review system and into court to get the coverage they are entitled to," Deford said. "It shouldn’t happen this way."
The lawsuit seeks an order from the U.S. District Court compelling Medicare to follow its own rules and to give proper consideration to the decisions handed down by its own judges to grant Medicare coverage.
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The Center for Medicare Advocacy, Inc., established in 1986, is a national nonprofit, nonpartisan organization that provides education, advocacy and legal assistance to help older people and people with disabilities obtain fair access to Medicare and necessary health care. The Center is headquartered in Connecticut and Washington, DC with offices throughout the country.