Jan 242014

Thanks to our colleagues at the Center for Medicare Advocacy for this update on the one-year anniversary of the settlement of the Jimmo case, which ended the long-standing “improvement standard.” On the heels of the Center’s new report that describes widespread confusion among Medicare beneficiaries, ongoing public outreach remains essential to ensuring access to care.

Below is a press release from the Center, with important updates on the settlement, the changes, and the new CMS manuals about it.

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 coverage 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 and a Medicare Learning Network (MLN) article along with hosting a national call for providers and Open Door Forums to get the word out.

“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 information with key provisions from the new Medicare Manuals to show their health care providers.


key words: Jimmo, improvement standard

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