Medicare Decision – 6 Years Later

I wrote about this decision here six and a half years ago. (Blog posts 3-25-13 and 4-1-13) The case is Jimmo vs. Sebelius and it corrected the misapplication of Medicare rules concerning coverage for rehabilitation services and therapy. The standard that had been applied for many years was whether the patient was improving as a result of the treatment, called the “Improvement Standard’. If not, then Medicare coverage would be terminated. This termination was often well short of the 100 days of coverage allowed under Medicare.

It is certainly easy to understand why this became the standard. With elderly patients suffering from dementia, Alzheimer’s, Parkinson’s and other noncurable illnesses, they often could not show sufficient improvement to avoid Medicare’s cutoff. Medical treatment is focused on curing a condition. The problem, however, was that this was never the standard as written. Instead, what determines whether Medicare Part A coverage for skilled nursing home stays, home health care and outpatient services will continue is whether those services are needed to maintain the patient’s current condition or prevent or slow further deterioration. This is what is termed the “Maintenance Coverage Standard”.

That was the issue at hand in the class action suit filed. The outcome of Jimmo v. Sebelius was a settlement in which the government agreed that the standard had been misapplied. The “Improvement Standard” had become so ingrained in the system that part of the settlement included a rewrite of Medicare manuals by the Center for Medicare and Medicaid Services (CMS). Even that, however, was not enough. 4 years later advocacy groups went back to court because of the government’s failure to comply. The Court approved a corrective statement intended to remind medical providers and patients that Medicare covers rehabilitation when a beneficiary needs skilled care in order to maintain function or to prevent or slow down the patient’s decline or deterioration. CMS was also supposed to provide additional training to Medicare providers on this issue.

It is now almost 3 years later and unfortunately the problem persists. A recent study by the Center for Medicare Advocacy revealed that 40% of Medicare providers, contractors and adjudicators were unaware of the Jimmo settlement. 30% were unaware that the “Improvement Standard” is the incorrect standard – that failure to make improvement is not justification to cut off rehabilitation services.

It is clear then that many Medicare patients are losing coverage for much needed rehabilitation services. It is, therefore, important that patients know the correct standard and insist it be applied correctly.