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.