On January 18, 2011 a federal district court in Vermont filed the lawsuit Jimmo V. Sibelius on behalf of the Center for Medicare Advocacy, representing plaintiffs, including Glenda R. Jimmo, Rosalie J. Berkowitz, along with numerous national organizations representing individuals with a wide range of chronic disabilities (National Multiple Sclerosis Society, the Parkinson’s Action Network, Paralyzed Veterans of America and the National Committee to Preserve Social Security and Medicare). The center filed suit against the federal government claiming that the long-standing use of “improvement standards” established by the Center for Medicare and Medicaid Services (CMS) has lead to thousands of Medicare beneficiaries to be denied critical rehabilitation services “on the grounds that their condition was stable, chronic, not improving, or that the necessary services were for “maintenance only.” The most recent data analysis by CMS puts the number of Medicare beneficiaries with disabilities (over and under 65) between 43.1 and 44.8 million Americans.
For years CMS has supported the policy of denying individuals, particularly those with long-term or debilitating conditions, critical outpatient, home health, and skilled nursing care. The scope of services is broad, and the philosophy archaic. Individuals receiving Medicare services currently undergo a re-evaluation every 60 days to see whether their condition is being improved by the care that has been prescribed by their doctor and further covered by Medicare. The problem lies in the fact that the majority of individuals seeking care such as home physical/occupational therapy or intermittent skilled nursing require it in order to stop their condition from further deteriorating. For example, it is not uncommon for individuals who suffer from paralysis as a result of their illness or injury to develop skin ulcers from a lack of mobility and circulation. These situations can be prevented when these individuals receive intermittent skilled nursing or home health care that can catch such problems before they develop or get worse. Such injuries can develop quickly and lead to life-threatening infections and are one of the leading causes of institutionalization of individuals with disabilities. Not only is denying such services to individuals with chronic and debilitating conditions immoral but it is simply fiscally irresponsible. Nursing home care can cost up to three times as much when compared to providing specific services to individuals in their own homes not to mention the overall psychological and medical benefits of being away from a facility crawling with other people’s germs that easily spread among the many different caregivers and workers who travel from room to room.
On October 16, 2012 a settlement was reached between the Center for Medicare Advocacy and CMS. After a judge approves the settlement, a process the Center for Medicare Advocacy says may take several months, “the agreement… will amend certain Medicare coverage rules. Medicare will pay for such services if they are needed to ‘maintain the patient’s current condition or prevent or slow further deterioration,’ regardless of whether the patient’s condition is expected to improve. In addition, federal officials agreed to revise the Medicare Benefit Policy Manual to clarify that Medicare coverage of nursing and therapy services ‘does not turn on the presence or absence of an individual’s potential for improvement,’ but is based on a beneficiary’s need for skilled care.”-(American Academy of Physical Medicine and Rehabilitation)
If you believe you have been unjustly denied Medicare or your therapy/home health/skilled nursing services were cut off from past services due to the “maintenance standard” consider consulting your doctor. The pending settlement will allow individuals with previously non-appealable decisions by Medicare on or after January 18, 2011 (the date at which the suit was filed) to have their claims re-reviewed, but as further indicated by the Center for Medicare Advocacy it is not necessary to wait until the settlement is approved for patients and advocates to act. It would be beneficial to begin the proper research to gain or regain lost services. For more information and to learn how the Jimmo V. Sibelius settlement may affect you I strongly urge you go to the Center for Medicare Advocacy Inc’s website- www.medicareadvocacy.org or call (860) 456-7790 at their national office in Connecticut. Other lines of contact are available on their website.