The Improvement Standard Under Jimmo v. Sebelius

For decades, Medicare beneficiaries, mainly those with long-term or debilitating conditions or those who need rehabilitation services have been denied necessary care based on the “Improvement Standard.” This is an illegal practice by CMS and its contractors that has resulted in Medicare coverage for vital care being denied to thousands of individuals on the grounds that their condition was stable, chronic, not improving, or that the necessary services were for “maintenance only.”

The agreement reached in Jimmo v. Sebelius, settles once and for all that Medicare coverage is available for skilled services to maintain an individual’s condition. Under the maintenance coverage standard that was articulated in the Jimmo Settlement, the determining issue regarding Medicare coverage is whether the skilled services of a health care professional are needed, and NOT whether the Medicare beneficiary will actually “improve.” Pursuant to Jimmo, medically necessary nursing and therapy services, provided by or under the supervision of skilled personnel, are coverable by Medicare if the services are needed to maintain the individual’s condition, or to slow their decline in condition.

The government insists that it is only clarifying what has always been the Medicare coverage standard and that the Settlement does not change Medicare laws or regulations. The law never supported the requirement that people improve in order to get Medicare, even though thousands of beneficiaries have been denied service for this reason.

Accordingly, health care providers should implement the maintenance standard now, and move away from a recovery standard. Patients should discuss the Medicare maintenance standard with their providers to determine if it is applicable to them.

According to CMS, they are working to implement the terms of the settlement and ensure that beneficiaries have access to the full range of services they are entitled to under the law. The settlement will clarify existing policy that claims should not be denied solely based on a rule-of-thumb determination that a beneficiary’s condition is not improving.” CMS will revise the Medicare Benefit Policy Manual and other Medicare Manuals to correct suggestions that Medicare coverage is dependent on a beneficiary “improving.”

If you need assistance understanding Medicare laws and regulations, consult our experienced health law attorneys for guidance.

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