Posts filed under ‘Jimmo vs. Sebelius’

It Isn’t That Complicated: You Don’t Have to Improve

As the New York Times reports today, people don’t have to improve to qualify for Medicare-covered care in most settings.  Unfortunately, older and disabled people are constantly told otherwise – and refused care as a result. The Centers for Medicare & Medicaid Services could fix this pretty easily.  Just issue a CMS Ruling stating definitively and clearly that skilled nursing and therapy can be covered to maintain a patient’s condition or slow deterioration.  It’s the law. Disseminate the Ruling to all Medicare providers and adjudicators.  Post it on the CMS website.

If there’s the will, there’s the way.

 

 

September 12, 2016 at 8:05 pm Leave a comment

Gabby Giffords Reminds Us Why Long Term Physical Therapy and Health Care Is So Important

From the New York Times, January 8, 2014

“…This past year, I have achieved something big that I’ve not spoken of until now. Countless hours of physical therapy — and the talents of the medical community — have brought me new movement in my right arm. It’s fractional progress, and it took a long time, but my arm moves when I tell it to. Three years ago, I did not imagine my arm would move again. For so many days, it did not. I did exercise after exercise, day after day, until it did. I’m committed to my rehab and I’m committed to my country, and my resolution, standing with the vast majority of Americans who know we can and must be safer, is to cede no ground to those who would convince us the path is too steep, or we too weak. “

How can we not stay the course? We will continue to advocate for those who need a voice – for the long term.

January 8, 2014 at 11:30 pm 1 comment

Judge Approves Settlement in Jimmo vs. Sebelius After Court Hearing

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

January 24, 2013 at 9:55 pm 2 comments

Annual Medicare Payment Limits for Home Health – Even Worse Than Co-Pays for Beneficiaries

The Center for Medicare Advocacy has represented Medicare beneficiaries since 1986. As one of the few advocacy organizations in the nation solely serving Medicare beneficiaries, we strongly oppose home health episodic payment caps or any other such defined payment limits. The counterpart to this notion, caps on outpatient therapy, has created significant barriers to necessary care for thousands of our clients with long-term and chronic conditions. We have no doubt that episode caps would be harmful to some of those in greatest need of home care. Thus, we are adamantly opposed to such limits in the home health context.

The Center has long opposed Medicare home health co-payments, and continues to do so. Like caps, co-payments will limit access to in-home care for those most in need of these services. However, we are increasingly concerned about proposals to introduce home health payment limits. There is no question that home health payment limits would be disproportionately harmful for people with conditions such as traumatic brain and spinal cord injuries, Alzheimer’s, Parkinson’s disease, MS, and other such illnesses and disabilities. Without the possibility for ongoing home health care, these individuals may well need costly nursing home or hospital care.

For example:
• Our client, Mrs. Berkowitz, who is 81 years old and receives skilled physical therapy and home health aide services for her Multiple Sclerosis and related health needs, will require a nursing home if payment caps are instituted for Medicare home health.
Payment caps contradict and undermine growing efforts to promote better care, at lower costs, by encouraging and investing in home and community-based services.

Payment caps would also undermine the settlement just arrived at with the U.S. Department of Health and Human Services in the national class action law suit, Jimmo vs. Sebelius. The Jimmo Settlement makes it clear that Medicare coverage is available for home health patients who need skilled nursing or therapy to maintain or slow deterioration of their conditions. Jimmo holds the promise of continuing care at home for people with long-term conditions who would otherwise often need more intense and expensive institutional care. Medicare home health payment caps, however, would create a barrier to this care and provide a disincentive to home health agencies to offer care to this particularly vulnerable population.

December 3, 2012 at 9:58 pm Leave a comment


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