Judge Approves Settlement in Jimmo vs. Sebelius After Court Hearing

January 24, 2013 at 9:55 pm 2 comments

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to ensure that those who need health services covered under the Medicare law are not denied based on an illegal, outdated rule of thumb.”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 lweybrew@douglasgould.com or 914-833-7093. Learn more about the Center for Medicare Advocacy at www.medicareadvocacy.org

Entry filed under: Improvement, Jimmo vs. Sebelius, Judith Stein. Tags: , .

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2 Comments Add your own

  • 1. Judith Stein  |  February 13, 2013 at 4:14 pm

    Go to our website: http://www.medicareadvocacy.org .

    Reply
  • 2. Robert Weiss  |  March 1, 2013 at 8:25 am

    CMS is in the middle of implementing a change in therapy reimbursement policy, replacing reimbursement from a “services provided” to a “measured functional disability improvement” basis. Data are being collected through the collection of non-reimbursed “Function-related G-Codes” and severity modifiers for every therapy encounter in 2013, with the intention of using these data for determination of a reimbursement schedule for 2014 and beyond. Treatment is terminated when improvement can no longer be shown. Current functional disability measurement tools do not measure severity of chronic progressive conditions such as lymphedema, where the purpose of therapy is to stop or retard degradation of the condition in order to prevent a decrease in functional disability. Improvement in the treated medical condition may not be measured by change in functional disability, but by changes in measurement, skin tone, skin fluid content, skin thickness, etc. In this case does Jimmo VS Sebelius conflict with the laws driving the upcoming change in therapy reimbursement schemes?

    Reply

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