Posts filed under ‘Improvement’
The Center for Medicare Advocacy, along with its co-counsel Vermont Legal Aid are pleased that the Settlement Agreement in the Medicare Improvement Standard case, Jimmo v. Sebelius, was approved January 24, 2013 at the conclusion of a scheduled fairness hearing, marking a critical step forward for thousands of beneficiaries nationwide.
The plaintiffs joined with the named defendant, Secretary of Health and Human Services Kathleen Sebelius, in asking the federal judge to approve the settlement of the case. With only one written comment received, and no class members appearing at the fairness hearing to question the settlement, Chief Judge Christina Reiss granted the motion to approve the Settlement Agreement on the record, while retaining jurisdiction to enforce the agreement in the future, as requested by the parties.
“We are not surprised but are very pleased that the judge ruled the settlement is fair, reasonable and adequate,” said Gill Deford, Litigation Director of the Center for Medicare Advocacy. “This moment is a culmination of two years of hard work, in conjunction with partners and advocates, to ensure that those who need health services covered under the Medicare law are not denied based on an illegal, outdated rule of thumb.”
With the settlement now officially approved, the Centers for Medicare & Medicaid Services (CMS) is tasked with revising its Medicare Benefit Policy Manual and numerous other policies, guidelines and instructions to ensure that Medicare coverage is available for skilled maintenance services in the home health, nursing home and outpatients settings. CMS must also develop and implement a nationwide education campaign for all who make Medicare determinations to ensure that beneficiaries with chronic conditions are not denied coverage for critical services because their underlying conditions will not improve.
“It is important to note that the Settlement Agreement standards for Medicare coverage of skilled maintenance services apply now – while CMS works on policy revisions and its education campaign,” said Judith Stein, Executive Director, Center for Medicare Advocacy. “We’ve been hearing from beneficiaries who are still being denied Medicare coverage based on an Improvement Standard. Coverage should be available now for people who need skilled maintenance care and meet any other qualifying Medicare criteria. This is the law of the land – agreed to by the federal government and approved by the federal judge. We encourage people to appeal should they be denied Medicare for skilled maintenance nursing or therapy because they are not improving.”
For people needing assistance with appeals, the Center for Medicare Advocacy has self-help materials available on its website, www.medicareadvocacy.org. This information can help individuals understand proper coverage rules and learn how to contest Medicare denials for outpatient, home health, or skilled nursing facility care.
“It is exciting to know that by this time next year, Medicare policies will clearly state that coverage for skilled maintenance nursing and therapy is available, and that a beneficiary’s access to coverage does not depend on the potential for improvement, but rather on the need for skilled care,” continued Stein.
To speak with a representative of the Center for Medicare Advocacy, please contact Lauren Weybrew at firstname.lastname@example.org or 914-833-7093. Learn more about the Center for Medicare Advocacy at www.medicareadvocacy.org
Few people understand the value of Medicare’s home health coverage. In fact, many people who qualify for Medicare instead pay out-of-pocket, go without needed care, look to Medicaid for payment, or even enter nursing homes unnecessarily. Learn about Medicare home health coverage from nationally known beneficiary advocates. This Wednesday, September 12th!
Medicare Home Health Coverage for People With Long-term and Chronic Conditions
Presented by: Judith Stein, Executive Director/Attorney and Margaret Murphy, Associate Director/Attorney
September 12 from 2:00 – 3:00 PM EDT
Unknown to most people with Medicare, and contrary to what is often stated by the Centers for Medicare & Medicaid Services (CMS), the Medicare home health benefit can provide long term coverage for those who qualify. This webinar will help advocates understand the potential of this important coverage so that people with long-term and chronic conditions can obtain the nursing, therapy and home health aide care they need to remain at home. The presenters will explain:
* Prerequisites to obtaining Medicare home health coverage;
* Real and imagined limitations to coverage;
* Advocacy tips for obtaining and maintaining coverage;
* How to appeal home health coverage denials.
Download Speaker Bios at http://www.naela.org/app_themes/public/PDF/Meeting%20PDFs/Webinar/2012sep12webinarbio.pdf
Yesterday the U.S. Department of Justice indicted a Texas doctor and six others for defrauding Medicare and Medicaid of $375 million. The doctor ordered home health care services that were unnecessary and never even delivered to Medicare beneficiaries. We agree that’s outrageous.
Catching these criminals is good news for the federal government, taxpayers, and Medicare beneficiaries – such massive fraud is exactly the type of waste in Medicare that needs to stop.
However, as good as this news is for Medicare, we have to ask: how does Medicare pay out hundreds of millions in fraudulent home health claims over half a decade, while denying home health coverage for our 80-year-old client in Maine with paraplegia?
Ms. M’s doctors ordered skilled nursing for wound care and physical therapy to maintain her ability to use her wheelchair in her home. She has a legitimate need for home health services, but the only home health agency in her area claims the Medicare agency will charge it with fraud if it bills Medicare, because she won’t improve. This goes directly against the Medicare regulations, which allow for services designed to maintain her level of function. Unfortunately this “Improvement Standard” is so ingrained in Medicare contractors and providers, that providers fear being accused of fraud if they bill for these legitimate services.
We are buoyed by the successful investigation by law enforcement in the Texas case. Such victories should leave more money for people like our client, who have legitimate home health needs that are coverable by Medicare.
Federal Judge Refuses To Dismiss Medicare Beneficiaries’ Challenge To The Medicare “Improvement Standard”
Plaintiffs have overcome a major hurdle in a lawsuit filed by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of Medicare beneficiaries with long-term and chronic conditions. In a comprehensive 35-page decision, Chief Judge Christina Reiss refused the federal government’s request to throw out a lawsuit that seeks to end use of an illegal Improvement Standard to deny Medicare coverage. The Improvement Standard is a “rule of thumb” that Medicare uses to deny or terminate coverage to beneficiaries whose conditions are not improving. Jimmo v. Sebelius, Civil No. 5:11-CV-17 (D. VT. 10/25/20011).
“The Improvement Standard is the most unfair and harmful reason for Medicare denials,” stated Judith Stein, executive director of the Center for Medicare Advocacy. “It has a particularly devastating effect on patients with chronic conditions such as Multiple Sclerosis, Alzheimer’s disease, ALS, Parkinson’s disease, and paralysis.”
The lawsuit, which was filed in January of this year, was brought on behalf of a nationwide class of Medicare beneficiaries by six individual beneficiaries and seven national organizations representing people with chronic conditions.
In asking the court to dismiss the case, the government raised several arguments to contend that the court lacked jurisdiction over the plaintiffs’ claims. The government also argued that the plaintiffs failed to state a claim, namely, that there was no proof that the government was even applying such a policy as the Improvement Standard. Judge Reiss rejected that contention. She did agree, however, that the court lacked jurisdiction over one beneficiary plaintiff and one organizational plaintiff, but the case will go forward with the remaining eleven plaintiffs.
“Judge Reiss understands the core issue plaintiffs in this case seek to address,” stated Michael Benvenuto, attorney for plaintiffs from Vermont Legal Aid. “They are not seeking individual claim reviews; they are challenging a broad secret policy.”
“This is a great first step for these plaintiffs and for Medicare beneficiaries in general,” remarked Gill Deford, the lead attorney for the plaintiffs. “The Improvement Standard has been used for over 30 years to deprive hundreds of thousands of Medicare beneficiaries of coverage they desperately needed. This decision starts the process of ending that illegal policy.”
Instead of raising the age of eligibility for Medicare, why don’t we just use Part D as a model and create a new Eligibility Donut Hole?
People ages 65 – 69 can keep their eligibility. But, between ages 70 and 85: Into the new Donut Hole. Eligibility for Medicare would end during this time – after all it’s these older people that start getting sick, so it’s the perfect time to stop paying for their health care. The new Donut Hole would save the government a ton of money!
Those who do make it through the Eligibility Donut Hole without Medicare, would once again become eligible at age 86. At that point most people only need “comfort measures” and their conditions usually won’t improve, so Medicare wouldn’t pay for their care anyway!
If the goal is to save money, a new Medicare Eligibiity Donut Hole is the way to go.
On January 18th, the Center for Medicare Advocacy, with co-counsel Vermont Legal Aid, filed a national class action law suit in federal district court to eliminate Medicare’s long-standing practice of denying coverage and access to care for people who are not going to improve, or improve sufficiently, or improve quickly enough.
This inappropriate “Improvement Standard” keeps people with long-term and chronic conditions from obtaining medically necessary health care and therapeutic services such as nursing, physical, occupational, and speech therapy. That is what happened to the lead plaintinff, Glenda Jimmo.
Ms. Jimmo, a 71-year-old resident of Vermont, was denied Medicare coverage for home health nursing and aide services on the grounds that she was stable despite the fact that she had diabetes, peripheral vascular disease, on-going circulatory problems, skin lesions, and is legally blind and has a below-the-knee amputation.
The lawsuit, Jimmo vs. Sebelius, No. 5:11-cv-17 (D. Vt.), was filed in Vermont federal court on behalf of five individual Medicare beneficiaries from Vermont, Connecticut, Rhode Island, and Maine, and five organizations, National Multiple Sclerosis Society, Parkinson’s Action Network, Paralyzed Veterans of America, National Committee to Preserve Social Security and Medicare, and American Academy of Physical Medicine and Rehabilitation. The federal government has 60 days to file it’s Answer to the lawsuit.
Improvement is NOT a legal standard upon which to determine eligibility for Medicare coverage. The Center for Medicare Advocacy hopes the Jimmo case will eliminate this harmful policy and practice once and for all.
The Center for Medicare Advocacy reiterates last week’s New York Times story: the Medicare Improvement Standard is an unjust danger to people in need of care!
We’ve been telling people that for years.
The Times article refers to two decisions, Anderson v. Sebelius and Papciak v. Sebelius, both regarding the Medicare “Improvement Standard.” For anyone not familiar, this is an arbitrary rule of thumb which essentially says that if the beneficiary won’t improve, Medicare won’t cover certain services.
The Improvement Standard has been used for years by Medicare contractors to improperly deny coverage.
However, per these two recent decisions, Medicare must adhere to the law as written, and pay for services if they are needed to maintain a person’s condition or to prevent deterioration of the person’s condition. The courts stated that Medicare beneficiaries do not have to prove that their condition will improve, as the government generally contends.
The rulings are potentially significant for many people with chronic conditions and disabilities like multiple sclerosis and Alzheimer’s disease; conditions which, by their very nature, simply will not improve. In the words of one judge, patients “need not risk a deterioration of [their] fragile health” to justify continuation of coverage for skilled care.
Center for Medicare Advocacy Director of litigation Gill Deford acted as co-counsel in one of the two cases. The Center has launched a campaign to end the Improvement Standard, and these decisions represent a significant victory.