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Jimmo v. Sebelius: The Court Case

Sunday, March 10, 2013

On January 24, 2013, settlement was approved in the Medicare “Improvement Standard” case, Jimmo v. Sebelius.  This settlement between the Secretary of Health and Human Services, Kathleen Sebelius, and the Center for Medicare Advocacy on behalf of Mrs. Jimmo and an entire class of Medicare beneficiaries, marks a critical step forward for thousands of beneficiaries nationwide.

Late in 2012, the Center for Medicare Advocacy and Secretary of Health and Human Services were able to come to an agreement about the Improvement Standard that has made it difficult or impossible for individuals with chronic, long-term conditions to receive Medicare benefits. 

The proposed agreement was filed in federal District Court on October 16, 2012 when the plaintiffs joined with the defendant in asking a federal judge to approve settlement of the case.  Because this case affects a large “class” (group) of beneficiaries rather than two individuals (plaintiff and defendant), the court held a fairness hearing in order for opinions and complaints to be heard.  Because the court received only one written comment, and no class members appeared at the fairness hearing to question the settlement, it appears that all were in agreement.  After the hearing, Chief Judge Christina Reiss approved the Settlement Agreement.

Jimmo v. Sebelius: What Happens Now?

As a result of the Jimmo Settlement, the determining issue regarding Medicare coverage is not whether the beneficiary will “improve.”  After this settlement, medically necessary nursing and therapy services are coverable by Medicare if the services are needed to maintain the individual’s condition, or prevent their decline.

With settlement now officially approved, the Centers for Medicare & Medicaid Services (CMS) is faced with the task of revising the Medicare Benefit Policy Manual to ensure that Medicare coverage is available for all beneficiaries who need long-term care.  The people who make determinations about who is eligible to receive Medicare coverage will now be unable to deny coverage to beneficiaries with chronic conditions simply because they are not improving. 

The court has insisted that this new maintenance standard is not a change in Medicare laws or standards, but instead that the current law had been misinterpreted in the first place.  The law never actually supported the requirement that beneficiaries be “improving” in order to receive coverage, but now the issue has officially been clarified.

Coverage should be available now for people who need skilled maintenance care and meet other qualifying Medicare criteria.  The settlement is also retroactive, meaning that if you were denied Medicare benefits based on the old Improvement Standard, there will be a re-review process to recover care expenses.  The Center for Medicare Advocacy encourages people to appeal should they be denied Medicare for skilled maintenance nursing or therapy because they are not improving, as this is not a valid reason for denial.

 

As an accredited attorney with the Veterans Administration, a member of the National Academy of Elder Law Attorneys, and the Washington State Bar Association, Elder Law Section, Darol Tuttle of Washington State, has helped numerous families plan for the future and protect their assets.  Please visit www.daroltuttle.com for more information. 

 

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