Jimmo v. Sebelius, No. 11-cv-17 (D. VT), is a nationwide class-action lawsuit brought on behalf of Medicare beneficiaries who received care in skilled nursing facilities, home health care, and outpatient therapy and who were denied Medicare coverage on the basis that they were not improving or did not demonstrate a potential for improvement (known as the “Improvement Standard). On January 24, 2012, the U.S. District Court for the District of Vermont approved a Settlement in Jimmo between attorneys for the Jimmo plaintiffs (the Center for Medicare Advocacy and Vermont Legal Aid) and the Centers for Medicare & Medicaid Services (CMS).
The Jimmo Settlement required CMS to undertake a number of steps to remedy the practice of erroneously denying Medicare coverage based on an “Improvement Standard:” Unfortunately, the Center still regularly hears from Medicare beneficiaries and their families about coverage denials for skilled care services based on some variation of an Improvement Standard.
Medicare coverage decisions should hinge on the need for such skilled care, and in meeting the various specific level-of-care criteria, (such as having a prior 3-day inpatient hospital stay for skilled nursing facility coverage). Coverage should not be denied because an individual has an underlying condition that won’t get better, (such as MS, paralysis, ALS diabetes, or Parkinson’s disease).
The Center for Medicare Advocacy has developed a Toolkit to help Medicare beneficiaries and their families respond to unfair Medicare denials. The Toolkit includes self-help materials to advocate for coverage of skilled nursing facility care that has been denied by providers, Medicare Advantage plans, and/or traditional Medicare. The Toolkit contains the following, to help obtain or restore Medicare when coverage is denied:
• Official information About Jimmo and Medicare SNF Coverage
• Information from the Center for Medicare Advocacy
• Center for Medicare Advocacy’s Frequently Asked Questions
• Self-Help Packet for Skilled Nursing Facility Appeals (Including for “Improvement Standard” Denials)
• Sample Letters for Skilled Care Professionals to Support Medicare Coverage
Although challenging a Medicare denial may seem daunting, beneficiaries and their representatives can win appeals when equipped with the right information. The Center for Medicare Advocacy hopes this Toolkit provides that information, to help beneficiaries, families, and advocates fight for fair Medicare coverage.