This diary follows up on KosAbility's October 2013 "...Better Care on Medicare: The Jimmo v Sibelius Win" (original key text and links recopied here as a unified resource), reporting that the Jimmo v Sebelius class action (settlement agreement approved January 24, 2013, in U.S. District Court, District for Vermont) had successfully challenged the pernicious unwritten "Standard of Improvement" rationale by which, for decades, Medicare beneficiaries were often denied coverage for many skilled medical services, on grounds that these services were only for patients who could show "restoration potential" (a.k.a., improvment).
On March 25, the New York Times online published A Quiet ‘Sea Change’ in Medicare on this landmark victory for the elderly and the disabled, won by years of unstinting battle by the Center for Medicare Advocacy, Inc. and its litigation partners, in the name of Glenda Jimmo and her co-plaintiffs, heroes all!
The website of the Center for Medicare Advocacy offers a wealth of useful, use-able materials for Medicare beneficiaries and caregivers, starting with the Fact Sheet pdf to give/copy to providers and insurers if they aren't in the loop, "Self Help Packets" to assist Medicare beneficiaries in considering whether the settlement may mean better care for them, and how to proceed further, and a great deal more.
The U.S. Department of Health & Human Services pdf, Manual Updates to Clarify ... Coverage Pursuant to Jimmo vs. Sebelius states the scope for services and care from/by:
**Skilled Nursing Facilities (SNFs),
**Inpatient Rehabilitation Facilities (IRF),
**Home Health Agencies (HHAs),
**therapy services under the Outpatient Therapy (OPT) Benefit,
**Critical Access Hospitals (CAHs),
rehabilitation agencies... physicians, certain non-physician practitioners, and therapists in private practiceas suppliers and providers for services and care including
physical therapy, occupational therapy, and speech/language pathology services.Following up on its Feb.4,2013 Therapy Plateau No Longer Ends Coverage report, the Mar.25 NYT article echoes the CMA's warning:
That means Medicare now will pay for physical therapy, nursing care and other services for beneficiaries with chronic diseases like multiple sclerosis, Parkinson’s or Alzheimer’s disease in order to maintain their condition and prevent deterioration.
But don’t look for an announcement about the changes in the mail, or even a prominent notice on the Medicare website. Medicare officials were required to inform health care providers, bill processors, auditors, Medicare Advantage plans, the 800-MEDICARE information line and appeals judges — but not beneficiaries. emphasis added
By the previous, decades-long rule of thumb, patients had to show capacity for improvement of their medical condition. Now the Medicare statute and regulations' actual language is required to prevail for medically indicated skilled care that is reasonable and necessary to slow or prevent deterioration of the medical condition, support functionality, alleviate suffering, improve quality of life.
At the time of the court decision, CMA explained:
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 [legal completion date January 23, 2014]. 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. http://www.medicareadvocacy.org/...Finally, the Jimmo vs Sebelius win gives teeth to the original, true Medicare language ... and to Medicare beneficiaries and their caregivers and families.
But we're still going to have to fight to secure these rights, patient by patient. The NYT points out:
Officials have posted a form beneficiaries can use to request reimbursement if they paid for care themselves. The form must be submitted by July 23, 2014, for claims with a final denial dating from Jan. 18, 2011, through Jan. 24, 2013.and, if beneficiaries or their caregivers meet pushback from their Medicare contractors (providers or insurers under Medicare Advantage plans) even after presenting the Factsheet, NYT advises:
...contact your state Quality Improvement Organization for help filing an expedited appeal. Ask the doctor who ordered treatment for a letter of support.Read the NYT articles for orientation (be aware it seems the NYT allows any individual online reader only ten free articles, and requires paid subscription for access after that), dig into the website of the Center for Medicare Advocacy for free access to Fact Sheets, forms, self-help packets, news, and other resources they provide(their site provides essentially everything linked in the NYT article, which references the CMA), and share the facts with everyone who's in need of knowing about them and using them.
If you receive the treatment and pay for it yourself (or are on the hook for the bill), [try] asking the provider to bill Medicare. Then you should appeal the denial by following the instructions provided on your Medicare summary notice or in the appeal decision letter. The Center for Medicare Advocacy’s website provides more details. If all else fails, email the center’s lawyers at firstname.lastname@example.org. They are meeting regularly with Medicare officials to monitor compliance with the settlement and [inform] the agency about coverage denials prohibited in the settlement.
Further links of interest:
A Physical Therapy viewpoint: Statement by APTA President...
An elder-care law viewpoint: Jimmo v. Sebelius
The story behind this case: Landmark Medicare Settlement Could Change Lives
The class action settlement pdf.