Certified Medicaid Planner Designation

Jimmo v. Sebelius: Update on Medicare Nursing Home Payment Class Action

Jimmo v. Sebelius: Update on Medicare Nursing Home Payment Class Action

Jimmo v. Sebelius

In 2007, Glenda Jimmo – a 78-year old Vermont mother of 4 – lost her right leg from Diabetes. Medicare will typically provide 20 days of full coverage and an additional 80 days of partial coverage for skilled care following a hospital stay. However, she was denied Medicare coverage as her condition was determined to be “unlikely to improve.”

The denial prompted a class-action law suit by Jimmo, along with the National Multiple Sclerosis Society, the Paralyzed Veterans of America, the Alzheimer’s Association, the National Committee to Preserve Social Security and Medicare, and the Parkinson’s Action Network. These groups represent those who are suffering from chronic conditions, and routinely denied Medicare coverage for this same reason.

While Medicare is supposed to provide coverage for 100 days of skilled services for eligible beneficiaries, many don’t receive the total 100 days. Once a patient reaches a point when they are no longer “improving,” Medicare reserved the right to stop coverage, based on the “improvement standard.” However, this was something that had crept into provider language but was never actually part of a properly articulated standard – hence the basis for the lawsuit. The federal court judge overseeing Jimmo’s case approved the settlement agreement, requiring Medicare to clarify its regulations to prevent future denials or discontinuations of what Medicare considers to be maintenance coverage.

A premature denial of Medicare can be very expensive to a family. Most Medicaid planners utilize the 100-day window to assist the family in preparation for Medicaid eligibility at the end of the 100-day period. In fact, depending on when the 100-day coverage period expires, this can often buy the family 4 full months in which to prepare for Medicaid eligibility. Premature denial of Medicare can accelerate the timetable and create a period of time where the family might have to pay full price for the cost of care when they otherwise would not have to do so.

With the forcible removal of this improvement standard, patients in nursing homes and other skilled health service centers can be more confident that they will not be denied Medicare coverage prematurely. These changes apply to those under Medicare Advantage as well as traditional Medicare. Medicare beneficiaries requiring skilled services to maintain or prevent deterioration regardless of underlying illness, disability, or injury in all three care settings covered by Medicare.

You would think the success in the class action would have been the slam-dunk Jimmo needed to revisit her appeal, but the Medicare Appeals Council rejected her appeal again, continuing to cite the improvement standard. In what can only be seen as high irony, Medicare has changed the rules that affect millions of Medicare beneficiaries and the catalyst poster-child for the reform gets jilted by the Medicare Appeals Council. This forced her attorneys to file another lawsuit in June of this year to force the issue again, and it was resolved with Jimmo finally receiving the coverage she and so many Americans deserve.

The denial in her own case continues to point out for advocates across the country the confusion that continues to exist on this matter even within the Medicare apparatus itself. For help understanding how Medicaid and Medicare interact, find a Certified Medicaid Planner™ in your area to assist with long-term care planning. For information on becoming a Certified Medicaid Planner to help your clients with these issues, click here.