Change in Medicare “Improvement Standard” Will Increase Access to Rehab Services

In a proposed federal class action lawsuit settlement agreement (Jimmo v. Sebelius) brought by the Center for Medicare Advocacy (CMA) and Vermont Legal Aide, the Centers for Medicare and Medicaid Services agreed to end an old practice — not a law or regulation — known as the Medicare Improvement Standard.

Prior to the settlement, people with Medicare had to show a likelihood of medical or functional improvement before Medicare would cover skilled nursing care or therapy services at home, a facility, or in outpatient services. The changes will apply to traditional Medicare plans and Medicare Advantage plans. 

Due to the agreement announced in mid-October, Medicare will cover rehabilitative services if they are needed to “maintain the patient’s current condition or prevent or slow further deterioration,” regardless of whether the person’s condition is expected to improve.

Glenda Jimmo, the lead plaintiff, is 76, has been blind since age 19, and uses a wheelchair. She was denied coverage for skilled nursing services in her home because she was deemed unlikely to improve.

“As the population ages and people live longer with chronic and long-term conditions, the government’s insistence on evidence of medical improvement threatened an ever-increasing number of older and disabled people,” CMA Director Judy Stein told the New York Times.

This change will potentially impact tens of thousands of people with Medicare who currently go without care or are forced to pay out of pocket.

In the proposed settlement agreement, the U.S. Department of Health and Human Services agreed to revise the manual to make it clear that skilled nursing care and therapy services will be covered in homes, outpatient clinics, and nursing homes, regardless of whether the person’s condition would improve. The department also promised to undertake a nationwide educational campaign to make the benefit known to medical providers and people with Medicare.

Many people whose claims for skilled nursing and therapy services were denied by Medicare before January 18, 2011, when the lawsuit was filed, will be able to have their claims reconsidered under the revised standards.

According to the Kaiser Family Foundation, about 46 percent of people with Medicare coverage have three or more chronic conditions, and about 8 percent use home health services — a figure that is expected to increase as a result of the settlement.

— by Carol Regan, PHI Government Affairs Director