February 16, 2017 Update on The Improvement Standard Case Jimmo v. Sebelius
The Centers for Medicare and Medicaid Services (CMS) has been ordered by the courts to publish a corrective statement to clarify that Medicare coverage is allowable to maintain an individual's condition or slow deterioration. There is no such thing as an improvement standard. Medicare recipients with chronic conditions cannot be denied coverage for therapy and nursing services because their underlying conditions are not expected to improve. Many people with chronic and progressive conditions, such as Parkinsons disease, multiple sclerosis, ALS, Alzheimer's disease, diabetes, hypertension, arthritis, heart disease, stroke and other serious conditions have a right to continue skilled therapy services not only for improvement, but also for maintenance puposes. For further information you can go to the Center for Medicare Advocacy Website https://www.medicareadvocacy.org/ or the CMS website.
You should no longer be told that an individual needs to be discharged from rehab therapy services becasue of a lack of improvement. If you are denied Medicare coverage there is an appeals process.
The Settlement applies to both Medicare Parts A and B so outpatient physical therapy, occupational thereapy, speech therapy and long term home health care are all covered. The Settlement is not limited to particular conditions, diseases or diagnoses. The Settlement Agreement applies to Medicare at home, outpatient therapy and in a skilled nursing home setting. "Maintenance therapy" can be covered it it requires a qualified therapist to ensure the care is safe and effective.
There is also an exception to the therapy payment cap. You will need the doctor to order the continued therapy and state in writing that a skilled therapist continues to be required for you to maintain you condition or slow deterioration.
The Settlement Agreement is retroactive and goes back to the date the case was filed, January 18, 2011. There is a review process for this. The denial must have come from Medicare and must be fore services that were actually recieved but no paid for by Medicare. CMS has posted a form for this on their website.
The corrective action plan must be completed no later than Sept 4, 2017 and includes among other things that CMS create a web page dedicated tothe Jimmo settlement agreement and post frequently asked questions.