Health and Disability

for many years, home health agencies and nursing homes who contract with Medicare routinely terminated Medicare coverage for a beneficiary who had stopped improving, even though nothing in the Medicare law required improvement as a condition for continued coverage.  In practice, both Medicare and the contract providers wrongfully applied an “improvement standard” to deny continued coverage to patients who had “failed to improve” or who had “plateaued”.  In short, once beneficiaries failed to show progress continued coverage was denied.  However, this misapplication of Medicare law was successfully challenged in a class-action lawsuit entitled Jimmo v. Sebelius, which was settled last year with nationwide impact. 

Under the settlement agreement, Medicare agreed to abandon its use of the so-called “improvement standard”.  It also agreed to revise its Medicare Benefit Policy Manual and to issue written instructions to its healthcare providers to make clear that continued  coverage of skilled nursing and therapy services does not turn on the presence of a beneficiary’s potential for improvement, but rather on whether he or she needs skilled care to “maintain” his or her current condition or to “slow further deterioration”.  Under the new policy, if your husband would be at risk for losing function or “backsliding”, then continued therapy ought to be provided and covered by Medicare.

Unfortunately, even though the Jimmo settlement is more than a year old,  we find that many healthcare providers are unaware of the end of the old “improvement standard”.  As a result, many seniors still experience premature Medicare coverage terminations because they are not improving.  This is especially problematic for person suffering with chronic conditions such as multiple sclerosis, Alzheimer’s disease, Parkinson’s disease, ALS, heart disease and stroke.  The good news, however, is that advocacy on your part can play a big role in correcting premature coverage terminations.

If you receive a notice that Medicare coverage is about to terminate, consider an immediate appeal.