• Skip to primary navigation
  • Skip to main content
  • Skip to primary sidebar
  • Skip to footer
  • Donate Now
  • Sign Up

Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

  • Eligibility/Enrollment
  • Coverage/Appeals
    • Medicare Costs (2021)
    • Self Help Materials – Toolkits & More
  • Topics
    • Basic Introduction to Medicare
    • COVID-19 and Medicare
    • Medicare Costs (2021)
    • Home Health Care
    • Improvement Standard and Jimmo News
    • Nursing Home / Skilled Nursing Facility Care
    • Outpatient Observation Status
    • Part B
    • Part D / Prescription Drug Benefits
    • Medicare for People Under 65
    • Medicare “Reform”
    • All Other Topics
    • Resources
      • Infographics
  • Publications
    • CMA Alerts
    • Fact Sheets & Issue Briefs
    • Infographics
    • The Medicare Handbook
    • SNF Enforcement Newsletter
    • Elder Justice Newsletter
    • Medicare Facts & Fiction
    • Articles by Topic
  • Litigation
    • Litigation News
    • Cases
    • Litigation Archive
    • Amicus Curiae Activities
  • Newsroom
    • Press Releases
    • Editorials & Letters to the Editor
    • CMA Comments, Responses, and Letters
    • Medicare Facts & Fiction
    • CMA in the News
  • About Us
    • Mission Statement
    • CMA FAQs
    • Personnel & Boards
    • The Center for Medicare Advocacy Founder’s Circle
    • Connecticut Dually Eligible Appeals Project
    • Ossen Medicare Outreach, Education and Advocacy Project
    • National Medicare Advocates Alliance
    • National Voices of Medicare Summit
    • CMA Webinars
    • Products & Services
    • Testimonials
    • Career, Fellowship & Internship Opportunities
    • Contact Us
  • Support Our Work
    • Donate Now
    • Join the Center for Medicare Advocacy Founder’s Circle
    • Take Action
    • Share Your Health Care Story
    • Tell Congress to Protect Our Care
    • Listen to Medicare & Health Care Stories
    • Sign Up

Jimmo v. Sebelius Improvement Standard Case Summary

May 30, 2013

Print Friendly, PDF & Email
 
Attorneys from the Center for Medicare Advocacy, Vermont Legal Aid and the Centers for Medicare & Medicaid Services (CMS) have agreed to settle the "Improvement Standard" case, Jimmo v. Sebelius, No. 11-cv-17 (D.VT), filed January 18, 2011.  A proposed settlement agreement was filed in federal District Court on October 16, 2012.  When the judge approves the proposed agreement, a process that may take several months, CMS will revise the Medicare Benefit Policy Manual and other Medicare Manuals to correct suggestions that Medicare coverage is dependent on a beneficiary "improving." New policy provisions will state that skilled nursing and therapy services necessary to maintain a person's condition can be covered by Medicare.

CMS will then undertake a comprehensive nationwide Educational Campaign to inform health care providers, Medicare contractors, and Medicare adjudicators  that they should not limit Medicare coverage only to beneficiaries who have the potential for improvement.  Instead, providers, contractors, and adjudicators must recognize "maintenance" coverage and make decisions based on whether a beneficiary needs skilled care that must be performed or supervised by a professional nurse or therapist.  Jimmo will be certified as a nationwide class.

As advocates, beneficiaries, and their families have long known, the Improvement Standard has harmed thousands of older and disabled Medicare beneficiaries who need skilled care to maintain their conditions.  Among those most affected are those with chronic conditions.  The effects of the Improvement Standard on beneficiaries with chronic conditions is underscored by the organizations that joined individual Medicare beneficiaries in challenging the Improvement Standard – the National Multiple Sclerosis Society, Parkinson's Action Network, Paralyzed Veterans of America, the Alzheimer's Association, United Cerebral Palsy, and the National Committee to Preserve Social Security and Medicare.

In an October 24, 2012 editorial, "A Humane Medicare Rule Change,"[3] The New York Times recognized the proposed settlement as reversing an "irrational and unfair approach to medical services" that developed "over decades because of Medicare's fragmented and loosely administered process for handling beneficiary claims."  The editorial praised the settlement as "clearly the humane thing to do for desperately sick people with little hope of recovery."

An important point, also identified by The New York Times, is that significant cost savings could result from applying the corrected coverage standard.  When Medicare beneficiaries receive medically necessary nursing and therapy services that enable them to maintain their functioning or prevent or slow their decline, many will be able to stay their homes and avoid expensive hospitalization and nursing home care.  

A key current public health initiative – reducing avoidable hospitalizations and rehospitalizations – is based on evidence that avoidable hospitalizations not only often result in poor outcomes for patients but also are enormously expensive for the Medicare program.  Under the Improvement Standard, beneficiaries were able to obtain care and treatment under the Medicare program only after their health deteriorated, often to the point of rehospitalization.  By preventing the inappropriate denial or premature discontinuation of Medicare coverage for beneficiaries, the Jimmo settlement should lead to smarter, and potentially less expensive, health care for many people and relief for their families.

What Can Beneficiaries Expect Now?

As CMS recognizes, the settlement does not change the underlying law and regulations governing the Medicare program.  Accordingly, since the underlying Medicare law is not changed, health care providers should implement the maintenance standard now. 

Patients should discuss with their health care providers the Medicare maintenance standard and whether it is applicable to them.  Health care providers should apply the maintenance standard and provide medically necessary nursing services or therapy services, or both, to patients who need them to maintain their function, or prevent or slow their decline.  Under the maintenance standard articulated in the settlement, the important issue is whether the skilled services of a health care professional are needed, not whether the Medicare beneficiary will "improve."

What Can Beneficiaries Do If They Were Denied Care Under the Improvement Standard?

The Jimmo settlement also establishes a process of "re-review" for Medicare beneficiaries who received a denial of skilled nursing facility care, home health care, or out-patient therapy services (physical therapy, occupational therapy, or speech therapy) that became final and non-appealable after January 18, 2011 because of the Improvement Standard.  Shortly after the federal district court approves the settlement, CMS will announce how beneficiaries can invoke the re-review process.  As more information becomes available, the Center for Medicare Advocacy will post information on its website.

Winning this historic class action lawsuit is just the beginning.
We need your support now to ensure the settlement is effectively implemented and communicated, ensuring full and fair access to Medicare and necessary health care for older and disabled Americans.
Be part of history by making your donation Today!

Filed Under: Article Tagged With: Litigation, The Improvement Standard

Primary Sidebar

Easy Access to Understanding Medicare

The Center for Medicare Advocacy produces a range of informative materials on Medicare-related topics. Check them out:

  • Medicare Basics
  • CMA Alerts
  • CMA Webinars
  • Connecticut Info & Projects
  • Health Care Stories
  • Se habla Español

Sign Up for CMA Alerts

Jimmo v. Sebelius

Medicare covers skilled care to maintain or slow decline as well as to improve.

Improvement Isn’t Required. It’s the law!

Read more.

Medicare: Build Back Better

By prioritizing Medicare beneficiaries and the health systems that serve them, we can avoid drastic national consequences. The Center for Medicare Advocacy proposes a five-part plan that will make Medicare a bulwark against the worsening health and economic challenges facing the American people.

learn more.

Latest Tweets

  • A recent study supports our concern about increasing out-of-pocket costs for #Medicare beneficiaries, proving that… https://t.co/FFwv77CBtW, 7 hours ago
@CMAorg

Footer

Stay Connected:

  • Contact Us
  • Sitemap
  • Products & Services
  • Copyright/Privacy

© 2021 · Center for Medicare Advocacy