Medicare beneficiaries must be covered for skilled nursing, home health and outpatient therapies if the services help them maintain their level of functioning, even if the patient is not "improving." This was made clear in the Jimmo v. Sibelius case, which I told you about in this prior post. The ruling was and is of particular importance to those with chronic conditions such as arthritis, cardiac disease, Parkinsons, etc. Unfortunately, seniors continue to be wrongly denied Medicare coverage based on the old improvement standard, even if the therapy or skilled care is preventing disease progression and halting further deterioration.
Well, things may be changing for the better. In response to a lawsuit brought by several Medicare advocacy organizations, on February 2 a federal judge ruled that Medicare must take specific steps to better educate agency staff about the elimination of the improvement standard. Among the required corrective actions: Medicare must maintain a web page devoted to the Jimmo v. Sibelius case clearly noting that improvement is not a criterion for coverage, and explaining how claims should be handled. In addition, the agency must provide appeals judges, claims processors and other relevant staff with new training. You can read the judge's ruling here. Medicare has until September 4 to comply. The government has 14 days to file an objection to the ruling.
So what does this all mean for you if you are a Medicare beneficiary or someone who is a caregiver for a Medicare beneficiary? First, be sure to discuss your care and coverage with your medical providers, bearing in mind that the only point is whether the services are necessary, not if they will produce improvement. If you are denied coverage on the basis of not meeting the improvement standard, your appeal will now have greater weight. (Information on Medicare appeals here.)