January 24, 2014 – Today marks the one-year anniversary of the landmark Jimmo v. Sebelius settlement. The Jimmo case was brought in 2011 by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of a nationwide class of Medicare beneficiaries who were denied Medicare coverage and access to necessary health care or therapy because they did not have sufficient potential for improvement. As a result of the Jimmo Settlement, Medicare cannot be denied in a nursing home, home care, or outpatient therapy setting based on an “Improvement Standard.”
The Settlement Agreement stipulates that the Centers for Medicare & Medicaid Services (CMS) must revise its Medicare manuals to clarify that coverage cannot be denied because an individual is not improving, or needs skilled care to maintain his or her condition. The final revisions, published in December 2013, now clearly state that improvement is not required to obtain Medicare coverage for Skilled Nursing Facilities (SNF), Home Health care (HH), or Outpatient Therapies (OPT). The Manual revisions also improve coverage for people who require intense rehabilitation in Inpatient Rehabilitation Facilities (IRF).
As CMS states in the Transmittal announcing the Jimmo Manual revisions:
No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition).
Additionally, per the Jimmo Settlement, CMS has implemented an Education Campaign to ensure that Medicare determinations turn on the need for skilled care – not on the ability of an individual to improve. CMS has issued Fact Sheets, a Medicare Learning Network (MLN) article, hosted a national call for providers, and Open Door Forums to get the word out. The CMS MLN Matters article is available here.
“The Jimmo Settlement, and implementation steps taken over the past year, will help thousands of Medicare beneficiaries nationwide who need care for long-term and chronic conditions,” said Judith Stein, founder and executive director of the Center for Medicare Advocacy. “We are working with our partners to ensure that providers, beneficiaries, and others who make Medicare decisions know that this is the law – now!”
The Center for Medicare Advocacy encourages people to appeal if they are told Medicare is not available for skilled maintenance nursing or therapy because they are not improving. There is a great deal of information and self-help material on the Center’s website, www.medicareadvocacy.org. Patients can also contact the Center for Medicare Advocacy or its website to obtain a card with key provisions from the new Medicare Manuals to show their health care providers.
Please contact Lauren Weybrew at firstname.lastname@example.org or call 646-214-0514 if you’d like to speak with a representative of the Center for Medicare Advocacy. Learn more about the Center for Medicare Advocacy, Inc. at https://www.medicareadvocacy.org
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 access to Medicare and necessary health care. We focus on the needs of Medicare beneficiaries, people with chronic conditions, and those in need of long-term care. The organization is involved in writing, education, and advocacy activities of importance to Medicare beneficiaries nationwide.