This week, the Center for Medicare Advocacy, a national nonprofit, released a new issue brief on an often-misunderstood aspect of coverage for people with chronic illness who need longer term care.
Titled “The Jimmo v. Sebelius Settlement Agreement: An Issue Brief for Medicare Providers,” the brief explains Jimmo v. Sebelius, a nationwide class action lawsuit that was brought on behalf of individuals with chronic conditions who had been incorrectly denied Medicare coverage. In 2013, a U.S. District Court approved the settlement agreement, which required the Centers for Medicare & Medicaid Services (CMS) to confirm that Medicare coverage is determined by a beneficiary’s need for skilled care, not their potential for improvement.
Prior to the settlement, many beneficiaries who needed care in settings like home health or nursing facilities found that their claims were denied on the basis that they were not improving. In addition, many providers thought that was the standard, and would refuse to provide care. The Center for Medicare Advocacy, along with Vermont Legal Aid, represented the plaintiffs and successfully argued that this interpretation of Medicare rules was incorrect and harmful.
The court case, Jimmo v. Sebelius (Jimmo), ended in a settlement where the federal government confirmed that Medicare coverage is determined by a beneficiary’s need for skilled care and does not rely on any potential for improvement. This applies to all Medicare beneficiaries throughout the country who are receiving care in home health, skilled nursing facilities, outpatient therapy, and inpatient rehabilitation hospitals and facilities. Today, the policy is clear: skilled care may be necessary to improve, maintain, or slow further deterioration of a patient’s condition.
The Jimmo Settlement clarifies that beneficiaries are eligible for skilled care when they need it and not just when the care might result in improvement. However, providers, beneficiaries, and advocates still encounter problems on occasion where claims are errantly denied. Because of this, the issue brief is a valuable resource that can help stakeholders better understand the rules in order to ensure people with Medicare get the care they need.
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