Jimmo v. Sebelius Settlement Agreement
June 4, 2014
For years, some people on Medicare had difficulty getting insurance coverage approved for physical therapy, occupational therapy and other treatments. The CMS pitch was that if the therapy is not helping to IMPROVE a patient’s condition, then it was not eligible for coverage. Coverage was denied because improvement could not be demonstrated. I’m sure we all have seen or heard of friends in this situation. Obviously this could be difficult to PROVE, especially in the case of chronic conditions, and the fact that this therapy may stabilize the condition or at best make it more tolerable was considered immaterial.
This is changing, thanks to the Jimmo v. Sebelius Settlement Agreement. This agreement is the result of a 2013 settlement of a lawsuit against the secretary of Health and Human Services Department, the parent agency of the Centers for Medicare and Medicaid Services (CMS), which oversee Medicare. The suit claimed that Medicare billing contractors were inappropriately denying coverage for skilled care by applying this improvement standard as a rule of thumb.
With this settlement it is now clear that if treatment is needed to prevent or slow further deterioration in patient’s condition, “coverage cannot be denied based on the absence of potential for improvement or restoration.” This revision applies to therapy in nursing homes, in outpatient clinics and at home.
While CMS has revised its manuals and notified providers of this change (although CMS calls it a clarification) patients may find themselves denied coverage because the provider hasn’t “gotten the word”. In these situations, the only recourse is for the patient to know his rights and call the change to the attention of the delinquent provider.
All of this information is available on www.cms.com. If coverage is denied because of lack of improvement, you can appeal using the process outlined on your Medicare statement.
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