End of Medicare Improvement Standard

Overview

Implications for Individuals on Medicare with Chronic Conditions

Resources

 

Overview

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 difficult  “Improvement Standard,” but will have access to these skilled services to maintain health, slow their decline and improve quality of life.

The government, through Medicare Part B, currently restricts therapy through a therapy cap system.The annual per beneficiary therapy cap amount for 2014 from now until March 31,2015 is $1920 for physical therapy and speech language pathology services combined and there is a separate $1920 amount allotted for occupational therapy services, up to a total benefit of $3700. Reaching these caps triggers a manual medical review (MMR). Manual Medical Review looks at medical necessity, reasonableness of care, and whether the services offered are inherently skilled.

You may qualify to get an exception to the therapy cap limits so that Medicare will continue to pay its share for your therapy services after you reach the therapy cap limits. Your therapist must

1.     Document your need for medically reasonable and necessary services in your medical record

2.     Indicate on your Medicare claim for services above the therapy cap that your outpatient therapy services are medically reasonable and necessary.

Click here to learn more.

 

Implications for INDIVIDUALS ON MEDICARE with Chronic Conditions


This settlement marks the end of a 30-year fight to alter the “Improvement Standard.”  Under application of the “Improvement Standard” only those whose treatment could be shown to improve their condition were covered under Medicare. This meant that people were routinely denied coverage for things like physical therapy, speech therapy, occupational therapy, speech language therapy and home healthcare.

With the correct interpretation of the standard, individuals affected by chronic progressive illness, such as HD, will be eligible for Medicare coverage for skilled services in nursing homes, outpatient therapy and even home health care services.

 

Resources

NEW: CMS manual updates to clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) coverage

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.

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