“Improvement Standard” not appropriate for Medicare coverage

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“Improvement Standard” not appropriate for Medicare coverage

Centers for Medicare & Medicaid Services

Many patients, and more importantly, many medical providers, still don’t know that the “improvement standard” is no longer an appropriate measure for Medicare’s coverage of skilled nursing and rehabilitative services for patients.

Frequently, Medicare providers deny or stop treatment of patients who are no longer improving from therapy or skilled nursing services. This “improvement standard” prevents many patients from receiving necessary care when their condition plateaus. While this standard presents a problem for many patients, it can specifically impact those with chronic or progressive conditions such as Parkinson’s, ALS, multiple sclerosis, and Alzheimer’s disease.

In 2011, the Center for Medicare Advocacy and Vermont Legal Aid filed a class-action lawsuit in the United States District Court for the District of Vermont challenging the improvement standard. The lead plaintiff’s name was Glenda Jimmo, and the case has become known as the Jimmo lawsuit. The case settled in 2013, and the government acknowledged that Medicare provides coverage for skilled services that are reasonable and necessary to prevent or slow the deterioration of the patient’s condition, even if the patient is not expected to improve.

By January 2014, the Centers for Medicare and Medicaid Services (CMS) was required to update program manuals, conduct an educational campaign to inform providers of the policy clarification, and randomly review claim denials to ensure the improvement standard was not still being applied.

Despite these efforts, providers and contractors continued to illegally deny care based on the improvement standard.

In 2016, the court ordered CMS to propose a corrective action plan. The accepted plan required CMS to create a web page dedicated to the improvement standard, publish a statement disavowing the improvement standard, post frequently asked questions relating to maintenance vs. improvement, develop and implement training for Medicare contractors and other decision makers, and conduct a national call to explain the maintenance coverage policy.

The Center for Medicare Advocacy says many patients are still being denied coverage based on the improvement standard. According to a recent article, which you can read here, many providers and contractors have not heard of the Jimmo settlement. The article encourages patients and families to educate themselves on this improvement standard so that they can appeal an incorrect denial of coverage.

For more information, you can visit the websites linked below:

  1. Jimmo v. Sebelius Settlement Agreement Fact Sheet
  2. CMS web page for Jimmo settlement information
  3. CMS Frequently Asked Questions web page

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