Medicare coverage for skilled nursing or therapy services can no longer be denied to beneficiaries who can’t show a likelihood of improvement.
The settlement in the Medicare Improvement Standard case, Jimmo v. Sebelius, was approved on January 24, 2013, marking a critical step forward for thousands of beneficiaries nationwide who require skilled nursing and therapy services to maintain their condition.
Coverage should be available now for people who need skilled maintenance care and meet any other qualifying Medicare criteria. People are encouraged to appeal should they be denied Medicare for skilled maintenance nursing or therapy because they are not improving.
The settlement is especially beneficial for patients with chronic conditions like Alzheimer’s disease, multiple sclerosis, Parkinson’s disease, stroke, spinal cord injuries and traumatic brain injury, as they will qualify for services more easily than before.
Until recently, beneficiaries had to show a likelihood of medical or functional improvement before Medicare would pay for skilled nursing and therapy services, according to some provisions of the Medicare manual and guidelines used by Medicare contractors. The insistence on evidence of medical improvement threatened an ever-increasing number of older and disabled people denied coverage for the skilled care of chronic conditions that aren’t curable and result in progressive disability.
With the settlement now officially approved, the Centers for Medicare & Medicaid Services (CMS) is tasked with revising 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.
Federal officials must make clear that Medicare coverage of nursing and therapy services “does not turn on the presence or absence of an individual’s potential for improvement,” but is based on the beneficiary’s need for skilled care. Also, CMS must 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.
The lead plaintiff in the case, Glenda R. Jimmo, 76, of Bristol, Vt., has been blind since childhood. Her right leg was amputated below the knee because of blood circulation problems related to diabetes, and she is in a wheelchair. She received visits from nurses and home health aides who provided wound care and other treatment, but Medicare denied coverage for those services, saying her condition was unlikely to improve.
Another plaintiff, Rosalie J. Berkowitz, 81, of Stamford, Conn., has multiple sclerosis, but Medicare denied coverage for home health visits and physical therapy, on the ground that her condition was not improving. Her family said she would have to go into a nursing home if Medicare did not cover the services.
Some 46 percent of Medicare beneficiaries have three or more chronic conditions, according to the Kaiser Family Foundation. About 8 percent use home health services — a figure that certainly will rise as a result of the settlement.
Under the terms of the settlement, more than 10,000 Medicare beneficiaries who were denied benefits for skilled services before January 18, 2011 (when the lawsuit was filed) will have their claims re-examined.
What does this mean for physicians?
- More patients with chronic conditions and disabilities qualify for home health care and may receive treatment at home, ensuring a continuum of care and reduction in costly hospitalizations and emergency care.
- Patients with chronic conditions like Alzheimer’s disease, multiple sclerosis, Parkinson’s disease, stroke, spinal cord injuries and traumatic brain injury will especially benefit from the new ruling.
- Patients and family caregivers will have needed support at home.