Unfair Medicare Denials Still Happen Based on an “Improvement Standard”

 Medicare beneficiaries are still experiencing coverage denials for skilled care services based on some variation of an “Improvement Standard”. Jimmo v. Sebelius is a nationwide class-action lawsuit brought on behalf of Medicare beneficiaries who received care in skilled nursing facilities, home health care and outpatient therapy and who were denied Medicare coverage on the basis they were not improving or did not demonstrate a potential for improvement (known as the “Improvement Standard”). A settlement was reached and Medicare published a revised Manual that emphasized that coverage for a skilled nursing facility (and home health or outpatient therapy) could not be based on a beneficiary’s ability to improve. (CMS Transmittal 179, Pub 100-02, 1/14/2014)
On February 2, 2017 the Court found CMS had not properly implemented the Education Campaign required by the Settlement and ordered the Medicare agency to carry out a Corrective Action Plan to remedy the problems. Unfortunately, denials based upon a beneficiary’s “lack of improvement” are still occurring.
The Center for Medicare Advocacy has created a “toolkit” to help Medicare beneficiaries and their families respond to unfair Medicare denials. The Toolkit includes self-help materials to advocate for coverage of skilled nursing facility care that has been denied by providers, Medicare Advantage plans and/or traditional Medicare. Although challenging a Medicare denial may seem daunting, beneficiaries and their representatives can win appeals when equipped with the right information. The Center for Medicare Advocacy provides this Toolkit to help beneficiaries, families and advocates fight for fair Medicare coverage. You can find them at www.medicareadvocacy.org
Ms. MacDonald’s practice is limited to Estate Planning, Probate & Trust Administration. Ms. MacDonald maintains her practice in the Santa Clarita Valley at 25115 Avenue Stanford, Suite A-209, Valencia, California. She can be reached at 661-294-6464.