Skip to main content

25-10-2012 | Article

Medicare to drop 'improvement standard' barrier to long-term care


Full statement

medwireNews: Thousands of elderly people with chronic conditions or disabilities may now qualify for Medicare coverage of skilled nursing care under the terms of a settlement between patient advocates and the US government.

The Center for Medicare Advocacy (CMA), a public interest law group, and the Centers for Medicare and Medicaid Services (CMS) have agreed to settle a class-action lawsuit centered on the so-called Medicare "Improvement Standard."

If the proposed settlement is accepted by the US District Court in Vermont, CMS will change the Medicare Benefit Policy Manual to remove language suggesting that skilled nursing or home health benefits are contingent upon a chance that a patient's condition will improve.

Under terms of the agreement, "CMS will undertake an Educational Campaign to get the word out to providers, contractors, and adjudicators that they should not be basing coverage on the potential for improvement, but on the need for skilled care," according to the CMA.

The lawsuit (Jimmo, et al vs Sebelius) argued that the Improvement Standard was never presented for public review and comment as required by law, but was instead "a covert rule of thumb that operates as an additional and illegal condition of coverage."

CMA and other patient advocates contend that tens of thousands of patients without a reasonable expectation of improvement in their conditions were denied Medicare coverage for skilled-nursing facilities or home healthcare, or had their benefits reduced or terminated because of the contested standard.

The Massachusetts Bar Association (MBA) notes that Medicare regulations explicitly state that " the restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities."

Judith Stein, Executive Director of the CMA and head of the legal team for the plaintiffs, told the New York Times that the denial of benefits was tantamount to denial of care, since most patients could not afford costly long-term care services.

The case is named for the lead plaintiff, Glenda Jimmo, 76, of Bristol, Vermont, who has been blind since childhood and has used a wheelchair since her right leg was amputated due to diabetes-related vascular problems. Because her condition is unlikely to improve, Medicare has denied coverage for visits from nurses and home-health aides who provide her with wound care and other services.

By Neil Osterweil, medwireNews reporter