Home Care Update - Jimmo v. Sebelius Plaintiffs Return to Court to Urge Enforcement

On Mar. 1^st, the Center for Medicare Advocacy and Vermont Legal Aid, filed a Motion for Resolution of Non-Compliance with the Settlement Agreement in the landmark case, Jimmo v. Sebelius. As a reminder, three years ago, the Centers for Medicare & Medicaid Services (CMS) was to fulfill its obligation to end the continued application of an “improvement standard” by Medicare providers and contractors to deny Medicare coverage for skilled maintenance nursing and therapy. LeadingAge New York has reported on this, beginning in 2013 and conducted a webinar in 2014.

This was a nationwide class of Medicare beneficiaries who were denied coverage and access to care because they did not show sufficient potential for “improvement.” This long-practiced standard was in direct contradiction to Medicare law. Under the Jimmo Settlement, it left no doubt that under the law and related regulations and policies, it is not necessary to improve in order to obtain Medicare coverage for skilled services. Medicare is available for skilled nursing and therapy to maintain an individual's condition or slow deterioration. This loss of skilled care based upon the lack of understanding on an improvement requirement is still occurring despite CMS’s thinking. They have completed the educational campaign that was required by the initial settlement.

“We are returning to the Court to ask for relief that CMS has refused to provide,” said Gill Deford, Director of Litigation for the Center for Medicare Advocacy, and lead counsel for the plaintiffs. “For over two years, we have tried repeatedly to get Medicare to take additional steps to make sure that providers and contractors knew that the days of using an Improvement Standard test have ended, but the agency would not do anything. We have provided overwhelming evidence that providers and contractors were not educated about the Settlement Agreement and that Medicare beneficiaries were still having their coverage terminated.”

We will keep members posted on the outcome of this latest lawsuit.

Cheryl Udell, cudell@leadingageny.org, 518-867-8871