Posts Tagged ‘Jimmo v. Sebelius’

CMS MLN ConnectsTM Conducting Call on Program Manual Updates Related to Jimmo v.Sebelius Lawsuit

December 6, 2013

On January 24, 2013, the U. S. District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius, involving skilled care for the IRF, SNF, HH, and OPT benefits. “Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage.”

The goal of this settlement agreement is to ensure that claims are correctly adjudicated in accordance with existing Medicare policy, so that Medicare beneficiaries receive the full coverage to which they are entitled. The settlement agreement sets forth a series of specific steps for CMS to undertake, including issuing clarifications to existing program guidance and new educational material on this subject.

As part of the educational campaign, this MLN Connects™ Call will provide an overview of the clarifications to the Medicare program manuals. These clarifications reflect Medicare’s longstanding policy that when skilled services are required in order to provide reasonable and necessary care to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration. In this context, coverage of skilled nursing and skilled therapy services “…does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.” Portions of the revised manual provisions also include additional material on the role of appropriate documentation in facilitating accurate coverage determinations for claims involving skilled care.

Program Manual Updates to Clarify SNF, IRF, HH, and OPT Coverage Pursuant to Jimmo v. SebeliusRegistration Now Open
Thursday, December 19; 2-3pm ET

To Register: Visit MLN Connects™ Upcoming Calls. Space may be limited, register early.

Target Audience: Skilled Nursing Facilities (SNFs); Inpatient Rehabilitation Facilities (IRFs); Home Health Agencies (HHAs); and providers and suppliers of therapy services under the Outpatient Therapy (OPT) Benefit.

• Clarification of Medicare’s longstanding policy on coverage for skilled services
•  No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims that require skilled care
• Enhanced guidance on appropriate documentation
Continuing education credit may be awarded for participation in certain MLN Connects Calls. Visit the Continuing Education Credit Information web page to learn more.

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Medicare Beneficiaries May See Increased Access To Physical Therapy Or Some Other Services

June 25, 2013

By Susan Jaffe, Kaiser Health News

For years, seniors in Medicare have been told that if they don’t improve when getting physical therapy or other skilled care, that care won’t be paid for. No progress, no Medicare coverage – unless the problem got worse, in which case the treatment could resume.

This frustrating Catch-22 spurred a class-action lawsuit against Health and Human Services Secretary Kathleen Sebelius. In January, a federal judge approved a settlement in which the government agreed that this “improvement standard” is not necessary to receive coverage. (more…)

CMS Issues Fact Sheet on Improvement Standard Changes

April 5, 2013

CMS has issued a fact sheet on the Jimmo v. Sebelius settlement agreement. The settlement agreement puts an end to the Medicare contractors inappropriately applying an “Improvement Standard” in making claims determinations for Medicare coverage involving skilled care. (more…)

Broader Therapies Could Further Strain Medicare

February 13, 2013

By Brett Norman, POLITICO

A lawsuit may have lit the fuse on a budgetary time bomb in Medicare, even though it simply reaffirms what should be a routine payment policy for services like physical therapy that the massive federal health care program has always had.

People on Medicare are entitled to various kinds of rehab and therapeutic services — occupational or speech therapy, for instance. But over the past 30 years or so, the coverage became spotty. Some people were able to get that care only if it could help them get better — not if it was aimed at keeping them stable or slowing a predictable decline. That became known as the “improvement standard.” The care was only for those who would improve. (more…)

MedPAC Reissues 2012 Recommendations

January 14, 2013

Last week, the Medicare Payment Advisory Commission met to finalize its 2013 Medicare recommendations to Congress. MedPAC reiterated its 2012 recommendations including the following:

  • The Secretary of the U.S. Department of Health and Human Services, with the Office of Inspector General, should conduct medical review activities in the counties that show aberrant home health utilization. The Secretary should implement the new authorities to suspend payments and the enrollment of new providers if they indicate significant fraud.
  • The Congress should direct the Secretary to begin a two-year rebasing of home health rates and eliminate the market basket increase.
  • The Secretary should revise the home health case mix system to rely on patient characteristics to set payments for therapy and non-therapy services and should no longer use the number of therapy visits as a payment factor.
  • The Congress should direct the Secretary to establish a per-episode copayment for HH episodes that are not preceded by hospitalization or post acute care use. (more…)

Medicare “Improvement Standard” No Longer Impedes Home Care

November 20, 2012

By Alicia Gallegos, American Medical News

Physicians are applauding a landmark settlement that will prohibit Medicare contractors from denying health coverage based on a patient’s potential for improved health status.

The agreement, which a federal judge must approve, is the result of a legal challenge by patients accusing the Centers for Medicare & Medicaid Services of using an “improvement standard” to measure a patient’s need for skilled home health care. Doctors and patient advocates said the standard has resulted in denials for necessary therapy and other home services for patients with chronic health conditions such as Parkinson’s disease, Alzheimer’s and multiple sclerosis. (more…)