KosAbility is a community diary series posted at 5 pm ET/2 pm PT every Sunday by volunteer diarists. This is a gathering place for people who are living with disabilities, who love someone with a disability, or who want to know more about the issues surrounding this topic. Our use of "disability" includes temporary as well as permanent conditions, and small, gnawing problems as well as big, life-threatening ones. Our use of "love someone" extends to beloved members of other species.
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The
Jimmo v Sebelius class action (settlement agreement approved January 24, 2013, in U.S. District Court, District for Vermont) 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."
By that 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 prevent or slow deterioration of the medical condition. This is new hope to save patients from avoidable suffering, and to improve quality of life and support functionality.
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/...
The Center for Medicare Advocacy, a nonprofit that helped Glenda Jimmo lead the way in this class action lawsuit, offers a
fact sheet pdf and extensive information about the case, also materials including "Self Help Packets" to assist Medicare beneficiaries in considering whether the settlement may mean better care for them, and how to proceed further.
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
Mon Oct 28, 2013 at 12:11 AM PT: "Under this settlement, Medicare policy will be clarified to ensure that claims from providers are reimbursed consistently and appropriately and not denied solely based on a rule-of-thumb determination that a beneficiary’s condition is not improving," said Fabien Levy, a spokesman for the U. S. Department of Health and Human Services, which includes the Medicare program. (as quoted in The New York Times at: http://newoldage.blogs.nytimes.com/....)
Mon Oct 28, 2013 at 12:16 AM PT: FREQUENTLY ASKED QUESTIONS ABOUT [The] JIMMO [v Sibelius "Improvement Standard" Case] SETTLEMENT Last modified: September 4, 2013 http://www.medicareadvocacy.org/...