Living With HD
Jimmo vs. Sebelius Settlement to Impact Medicare Beneficiaries
On January 24, 2013, the U. S. District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius, a class action lawsuit filed in 2011 against the “Improvement Standard” included in Medicare. The “Improvement Standard” was a misapplication of law that required a Medicare beneficiary to prove that home health and skilled nursing care would improve their medical condition. After this settlement, individuals will no longer need to meet the onerous “Improvement Standard,” but will have access to these skilled services to maintain health or slow their decline. According to the terms of the settlement agreement, the Centers for Medicare & Medicaid Services (CMS) will complete the manual revisions and educational campaign by January 23, 2014, which is within one year of the approval date of the settlement agreement.
This settlement marks the end of a 30-year fight to alter the “Improvement Standard.” Under application of the “Improvement Standard” only those with whose treatment could be shown to improve their condition were covered under Medicare. This meant that patients suffering from chronic conditions were denied coverage for things like physical therapy, speech therapy, occupational therapy and home healthcare. The settlement applies to anyone who requires skilled services to maintain or slow deterioration regardless of the underlying illness, disability or injury.
With the correct interpretation of the standard, individuals affected by chronic illness will be eligible for Medicare coverage for skilled services in nursing homes, outpatient therapy and even home health care services. The focus of this change is to emphasize maintenance therapy, which ideally will minimize the occurrence of acute events in individuals suffering from chronic conditions.
With the settlement now officially approved, the Centers for Medicare & Medicaid Services (CMS) now has a year to revise its Medicare Benefit Policy Manual and numerous other policies, guidelines and instructions to ensure that Medicare coverage is available for skilled maintenance services in the home health, nursing home and outpatient settings. CMS must also develop and implement a nationwide education campaign for all who make Medicare determinations to ensure that beneficiaries with chronic conditions are not denied coverage for critical services because their underlying conditions will not improve.
CMS Fact Sheet outlining the Jimmo v. Sebelius. settlement. Use this fact sheet as evidence that skilled maintenance services are coverable for skilled nursing facility care, outpatient therapy, and home health care.
Center for Medicare Advocacy Self Help Packet The Center for Medicare Advocacy developed a self help packet to provides individuals with the information needed to successfully appeal a home health agency’s Medicare denial, including “improvement standard” denials.
Jimmo FAQs This list of frequently asked questions is provided by the Center for Medicare Advocacy to better understand the settlement.
Implementing the Jimmo Settlement American Health Lawyers Association presentation about the implementation of the JIMMO settlement
What can individuals do if they were denied care?
The Jimmo settlement 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.
For people needing assistance with appeals, the Center for Medicare Advocacy has self-help materials available. This information can help individuals understand proper coverage rules and learn how to contest Medicare denials for outpatient, home health, or skilled nursing facility care.READ MORE