Judge Approves Medicare Improvement Standard Settlement

Upon hearing from advocates that Medicare denied therapy services because their condition had not “improved,” the Parkinson’s Action Network joined the Center for Medicare Advocacy in filing a class action lawsuit against the U.S. Department of Health and Human Services to remove Medicare’s Improvement Standard measurement for Parkinson’s and other degenerative diseases. 

The Center for Medicare Advocacy, along with its co-counsel Vermont Legal Aid are pleased that the Settlement in the Medicare Improvement Standard case, Jimmo v. Sebelius, was approved on January 24, 2013 during 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.

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 outpatient 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. The Center is hearing from beneficiaries who are still being denied Medicare coverage based on an Improvement Standard, but 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. 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.

For more information, contact executive director Judith Stein ([email protected]) or litigation director Gill Deford ([email protected]) in the Center for Medicare Advocacy's Connecticut office at (860) 456-7790.