Medicare Settlement Means No More ‘Improve or You’re Out’

A federal judge has approved the proposed Settlement Agreement in the Medicare Improvement Standard case, Jimmo vs. Sebelius, clearing the way for thousands of Medicare beneficiaries to receive needed health services to maintain their current level of functioning.

The settlement, which represents a significant change in Medicare coverage rules, ends Medicare’s longstanding practice of requiring people to show a likelihood of improvement in order to receive coverage of skilled care and therapy services.

The Agreement, which is retroactive to the date the suit was filed —  January 18, 2011 — includes skilled services covered by Medicare Part A and Part B, such as speech, occupational or physical therapy, nursing and home health services, even when the goal is maintaining the patient’s current condition rather than requiring that the patient improve.

“We are not surprised but are very pleased that the judge ruled the settlement is fair, reasonable and adequate,” said Gill Deford, Litigation Director of the Center for Medicare Advocacy. “This moment is a culmination of two years of hard work, in conjunction with partners and advocates, to ensure that those who need health services covered under the Medicare law are not denied based on an illegal, outdated rule of thumb.”

The Medicare law has never supported the “improvement standard.” Nevertheless, for decades beneficiaries have been denied needed services because they are not improving or have “plateaued,” sometimes with devastating results. The Center for Medicare Advocacy says providing maintenance services will save money in the long run, preventing decline, hospitalizations and need for more expensive services.

The official approval of the settlement means the Centers for Medicare and Medicaid Services (CMS) must develop and implement an education campaign to ensure that Medicare providers are not denying coverage for vital maintenance services to those with any chronic illness who meet other qualifying Medicare requirements. These illnesses include, but are not limited to, Parkinson’s disease, Alzheimer’s or other dementia, strokes, heart disease, multiple sclerosis, diabetes or paralysis.

The “maintenance standard” is effective immediately. If you or someone you are caring for has a chronic illness and needs skilled services to prevent further deterioration, contact your health provider. The Center for Medicare Advocacy is offering a number of resources including Frequently Asked Questions and self-help packets for those appealing denials.