Settlement Agreement Confirms Medicare Coverage for Skilled Maintenance Services Regardless of “Improvement”

Settlement Agreement Confirms Medicare Coverage for Skilled Maintenance Services Regardless of “Improvement”

Medicare beneficiaries can no longer be denied necessary skilled maintenance services provided in the home health, nursing home or outpatient therapy settings on the basis of showing no improvement, according to a settlement agreement approved on January 24, 2013. Legally this has always been the case. Yet, in practice, thousands of Medicare beneficiaries have been denied coverage because of the “improvement standard” – deciding whether to continue services based on the patient’s condition.

This Settlement in the Medicare “improvement standard” case, Jimmo v. Sebelius, is a huge win for beneficiaries, especially those with chronic and debilitating conditions such as Alzheimer’s disease, Parkinson’s disease, Multiple Sclerosis or ALS. These conditions will not improve, but without skilled services, the beneficiary will deteriorate. In such cases, skilled services are necessary to maintain one’s condition, or prevent or slow the decline.

The Settlement Agreement applies retroactively to the date the case was filed on January 18, 2011. Beneficiaries, their family members and providers need not wait for the law or regulations to be changed, as the law never supported the “improvement standard” in the first place. The Centers for Medicare and Medicaid Services will revise its many policy, benefit and instruction manuals, as well as plan and implement a nationwide education campaign for both beneficiaries and providers. We are spreading the word now to make sure that:

    1. All beneficiaries, their families and providers know of this clarification in Medicare’s coverage of necessary skilled maintenance services.
    2. The practice of denying services using the “improvement standard” stops.
    3. Beneficiaries who are denied necessary skilled maintenance services know they can appeal.

The settlement applies to both Medicare Parts A and B, including outpatient physical therapy, occupational therapy and speech therapy, and long term home health care under Part B. It applies regardless of whether one is in a Medicare Advantage plan or has Original fee-for-service Medicare. If you have been denied skilled services due to the “improvement standard” and need help with the appeal, please contact your local HICAP (Health Insurance Counseling & Advocacy Program) at 1-800-434-0222.

For more details on the Settlement Agreement, see a summary of the case from the Center for Medicare Advocacy as well as client stories exemplifying just how important this ruling is for those with chronic and/or disabling conditions. Below is a short youtube video of one woman’s story.

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.