Medicare Available For Chronic Conditions (End of Improvement Standard), But Word Slow To Get Out!!!
Article By: Gene Osofsky of the law offices of Osofsky & Ofsofsky, Elder Law; SF East Bay CA; Named "Super Lawyer" for Northern California in Elder Law
Q. Following my husband’s return home from a hospital stay, Medicare paid for a home health agency to give him therapy at home. However, we were just told that Medicare would stop paying for these visits because his condition was not improving. Does that sound right?
A. No, it does not. (at the end of this article is the link for finding the Medicare Appeals Packets for your denial situation).
Some background may be helpful: for many years, home health agencies and nursing homes who contract with Medicare routinely terminated Medicare coverage for a beneficiary who had stopped improving, even though nothing in the Medicare law required improvement as a condition for continued coverage. In practice, both Medicare and the contract providers wrongfully applied an “improvement standard” to deny continued coverage to patients who had “failed to improve” or who had “plateaued”. In short, once beneficiaries failed to show progress continued coverage was denied. However, this misapplication of Medicare law was successfully challenged in a class-action lawsuit entitled Jimmo v. Sebelius, which was settled last year with nationwide impact.
Under the settlement agreement, Medicare agreed to abandon its use of the so-called “improvement standard”. It also agreed to revise its Medicare Benefit Policy Manual and to issue written instructions to its healthcare providers to make clear that continued coverage of skilled nursing and therapy services does not turn on the presence of a beneficiary’s potential for improvement, but rather on whether he or she needs skilled care to “maintain” his or her current condition or to “slow further deterioration”. Under the new policy, if your husband would be at risk for losing function or “backsliding”, then continued therapy ought to be provided and covered by Medicare.
Unfortunately, even though the Jimmo settlement is more than a year old, we find that many healthcare providers are unaware of the end of the old “improvement standard”. As a result, many seniors still experience premature Medicare coverage terminations because they are not improving. This is especially problematic for person suffering with chronic conditions such as multiple sclerosis, Alzheimer’s disease, Parkinson’s disease, ALS, heart disease and stroke. The good news, however, is that advocacy on your part can play a big role in correcting premature coverage terminations.
If you receive a notice that Medicare coverage is about to terminate, consider an immediate appeal. Talk to your husband’s doctor and ask for a written chart note that continued therapy is necessary for your husband to “maintain” function and/or to “slow further deterioration”. To further aid you in your appeal, download the excellent Self-help Packets available for free on the website of the Center for Medicare Advocacy at www.MedicareAdvocacy.org, or by calling 860-456-7790. Individualized Self-Help Packets are available for denials of outpatient therapy, home healthcare, nursing home, and the misuse of hospital “observation status”.
So, based upon the Jimmo class action and the end of the so-called “improvement standard”, your husband may be entitled to continued covered therapy. Remember that advocacy does work. Also, by educating your husband’s providers as to the new rule under the Jimmosettlement, you may also indirectly help other patients who might have been similarly misinformed and could themselves benefit from continued covered therapies.
FROM THE MEDICARE
On December 9, 2013, the Secretary published the manual revisions. She also began the Educational Campaign, which involved memoranda, articles, National Calls, and other efforts to educate adjudicators, contractors, and others who carry out Medicare policy, about the "clarifications" to the manuals spelling out that there is no Improvement Standard. Plaintiffs' counsel continued to monitor and comment on the Secretary's actions to ensure that the settlement is carried out correctly, and had their first post-settlement meeting with opposing counsel on January 6, 2014. Class members’ opportunity to seek re-review of claims previously denied under the Improvement Standard began on January 24, 2014. Class members have until either July 23, 2014 or January 23, 2015 to seek re-review of their denied claim for coverage, with the deadline geared to when they received their adverse decision. The re-review form and information on filling it out and the applicable timelines can be downloaded from The Center For Medicare Advocacy at:
http://www.medicareadvocacy.org/take-action/self-help-packets-for-medicare-appeals/
Article By: Gene Osofsky of the law offices of Osofsky & Ofsofsky, Elder Law; SF East Bay CA; Named "Super Lawyer" for Northern California in Elder Law
Q. Following my husband’s return home from a hospital stay, Medicare paid for a home health agency to give him therapy at home. However, we were just told that Medicare would stop paying for these visits because his condition was not improving. Does that sound right?
A. No, it does not. (at the end of this article is the link for finding the Medicare Appeals Packets for your denial situation).
Some background may be helpful: for many years, home health agencies and nursing homes who contract with Medicare routinely terminated Medicare coverage for a beneficiary who had stopped improving, even though nothing in the Medicare law required improvement as a condition for continued coverage. In practice, both Medicare and the contract providers wrongfully applied an “improvement standard” to deny continued coverage to patients who had “failed to improve” or who had “plateaued”. In short, once beneficiaries failed to show progress continued coverage was denied. However, this misapplication of Medicare law was successfully challenged in a class-action lawsuit entitled Jimmo v. Sebelius, which was settled last year with nationwide impact.
Under the settlement agreement, Medicare agreed to abandon its use of the so-called “improvement standard”. It also agreed to revise its Medicare Benefit Policy Manual and to issue written instructions to its healthcare providers to make clear that continued coverage of skilled nursing and therapy services does not turn on the presence of a beneficiary’s potential for improvement, but rather on whether he or she needs skilled care to “maintain” his or her current condition or to “slow further deterioration”. Under the new policy, if your husband would be at risk for losing function or “backsliding”, then continued therapy ought to be provided and covered by Medicare.
Unfortunately, even though the Jimmo settlement is more than a year old, we find that many healthcare providers are unaware of the end of the old “improvement standard”. As a result, many seniors still experience premature Medicare coverage terminations because they are not improving. This is especially problematic for person suffering with chronic conditions such as multiple sclerosis, Alzheimer’s disease, Parkinson’s disease, ALS, heart disease and stroke. The good news, however, is that advocacy on your part can play a big role in correcting premature coverage terminations.
If you receive a notice that Medicare coverage is about to terminate, consider an immediate appeal. Talk to your husband’s doctor and ask for a written chart note that continued therapy is necessary for your husband to “maintain” function and/or to “slow further deterioration”. To further aid you in your appeal, download the excellent Self-help Packets available for free on the website of the Center for Medicare Advocacy at www.MedicareAdvocacy.org, or by calling 860-456-7790. Individualized Self-Help Packets are available for denials of outpatient therapy, home healthcare, nursing home, and the misuse of hospital “observation status”.
So, based upon the Jimmo class action and the end of the so-called “improvement standard”, your husband may be entitled to continued covered therapy. Remember that advocacy does work. Also, by educating your husband’s providers as to the new rule under the Jimmosettlement, you may also indirectly help other patients who might have been similarly misinformed and could themselves benefit from continued covered therapies.
FROM THE MEDICARE
On December 9, 2013, the Secretary published the manual revisions. She also began the Educational Campaign, which involved memoranda, articles, National Calls, and other efforts to educate adjudicators, contractors, and others who carry out Medicare policy, about the "clarifications" to the manuals spelling out that there is no Improvement Standard. Plaintiffs' counsel continued to monitor and comment on the Secretary's actions to ensure that the settlement is carried out correctly, and had their first post-settlement meeting with opposing counsel on January 6, 2014. Class members’ opportunity to seek re-review of claims previously denied under the Improvement Standard began on January 24, 2014. Class members have until either July 23, 2014 or January 23, 2015 to seek re-review of their denied claim for coverage, with the deadline geared to when they received their adverse decision. The re-review form and information on filling it out and the applicable timelines can be downloaded from The Center For Medicare Advocacy at:
http://www.medicareadvocacy.org/take-action/self-help-packets-for-medicare-appeals/