The Jimmo Case and the Medicare Improvement Standard

by David Goldfarb

A settlement agreement in the 2013 case of Jimmo v. Sebelius clarified the “improvement standard” that Medicare used when determining when to grant benefits for skilled nursing care, outpatient therapy, or home health care. Now, anyone seeking benefits for these types of care should fully know their rights under the agreement.

Prior to the case, many Medicare contractors used an improvement standard that would only grant coverage for treatment if a patient could be restored to previous capabilities or have a condition improve. Since many patients suffered from conditions that would not allow improvement or restoration, Medicare contractors denied them benefits for skilled nursing care, outpatient therapy, and home health assistance. The plaintiffs in Jimmo claimed that the defendants inappropriately used this standard to deny benefits for skilled nursing and therapy services.

While Medicare contractors can rightfully use an improvement standard in regard to some benefits, the Jimmo case reached a settlement agreement that the court approved. It states this standard is not appropriate for skilled care and services. Instead, Medicare should cover skilled nursing services under the following circumstances:

When such services are needed for maintenance of a patient’s current condition, to prevent deterioration of the patient’s condition, or even to slow deterioration of the patient’s condition.

Medicare should cover skilled therapy services if the following is true:

An individual clinical assessment shows that a qualified therapist’s specialized skills, judgment, and knowledge are needed to safely and effectively administer maintenance care. Such care must be needed to maintain a patient’s current condition, to prevent deterioration of the patient’s condition, or even to slow deterioration of the patient’s condition.

Therefore, it is not necessary for a patient to demonstrate that skilled care will improve their condition or restore them to a previous condition. Instead, they must only show that they need such care to slow or prevent deterioration to receive Medicare benefits.

This settlement does not change the improvement standard for other types of care—those standards may stand in other situations. In addition, the settlement still requires that a patient demonstrates through sufficient assessment and documentation that a certain type of skilled care is necessary to slow or prevent deterioration.

The settlement did not actually expand Medicare benefits or eligibility in any way but simply clarified Medicare’s existing policies that contractors and claim adjudicators had misapplied. It also required that contractors and claim adjudicators receive education on the proper eligibility standards, as well as patients seeking Medicare benefits for such services.

Contact a New York Elder Law Attorney to Review Your Situation Today

Navigating Medicare eligibility requirements can prove complicated—meanwhile, you may require those critical benefits to receive the care that you need. Hire an experienced Medicare attorney to handle your claim to ensure you receive all of the coverage you deserve. If you need assistance regarding any type of senior health benefits or how to plan ahead for coverage, please do not wait to consult with Goldfarb Abrandt & Salzman LLP. Call our office at (212) 387-8400 or contact us online today.