Mar 21

Plaintiffs Go Back to Court to Enforce Settlement Ending Medicare’s Improvement Standard

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The plaintiffs in Jimmo v. Sebelius, the landmark settlement that was supposed to end Medicare’s “improvement standard,” are back in court to try to force the Centers for Medicare & Medicaid Services (CMS) to fulfill its obligation under the settlement.

Under the settlement agreement in Jimmo v. Sebeliusthe federal government agreed to end Medicare’s longstanding practice of requiring that beneficiaries with chronic conditions and disabilities show a likelihood of improvement in order to receive coverage of skilled care and therapy services.  Medicare is required to cover skilled care as long as the beneficiary needs it, even if the care would simply maintain the beneficiary’s current condition or slow further deterioration. 

Medicare conducted an educational campaign and updated its benefit policy manual, but three years after the settlement, the Center for Medicare Advocacy is still getting reports that many Medicare providers continue to deny coverage to individuals who are not improving. In response, the Center for Medicare Advocacy and Vermont Legal Aid, co-counsels for the original plaintiffs in the Jimmo case, have filed a motion for resolution of non-compliance with the settlement order in district court in Vermont.

“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’ve provided overwhelming evidence that providers and contractors were not educated about the Settlement Agreement and that Medicare beneficiaries were still having their coverage terminated.”