CMA || Improvement Standard

May 23, 2012

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Improvement Standard

Removing a Major Barrier to Necessary Care: The Medicare "Improvement Standard" Advocacy & Education Initiative

Medicare Class Action Lawsuit – Jimmo v. Sebelius, No. 5:11-CV-17 – seeks to End Illegal Medicare "Improvement Standard"
- Press Release, 1/18/11
- Audio Press Conference, 1/18/11 (streaming)

The Center for Medicare Advocacy is launching a new advocacy and education initiative to eliminate the Medicare "Improvement Standard," which requires that Medicare beneficiaries be able to improve in order to qualify for coverage. The insistence that people must be able to get better unfairly restricts access to Medicare coverage and necessary health care.

Although the Improvement Standard conflicts with the law, it has become deeply ingrained in the system and ardently followed by those who provide care and those who make coverage determinations throughout the health care continuum. Beneficiaries are told Medicare coverage is not available if their underlying condition will not improve, if they have "plateaued," are not likely to improve, or if they need "maintenance care only". As a result it keeps people with debilitating, chronic conditions from receiving the care they need. This practice persists although the Medicare Act does not require improvement as a precondition to coverage for illness or injury. Further, the federal regulations state that "restoration is not to be the deciding factor" in making Medicare coverage determinations.

Everyday the Improvement Standard blocks access to Medicare and health care for real people. The people most affected by this barrier include people with Multiple Sclerosis, Alzheimer's disease, ALS (Lou Gehrig's disease), spinal cord injuries, diabetes, Parkinson's disease, hypertension, arthritis, heart disease, and stroke. Further, the erroneous standard disproportionately affects people who have low-incomes, as well as African-Americans and Hispanics.

With support from The Atlantic Philanthropies, the Center for Medicare Advocacy will begin a focused, collaborative effort to eliminate the Improvement Standard in Medicare policy and practice. This effort will include advocacy with the administration, litigation if needed, and a multi-faceted education campaign.

The Center for Medicare Advocacy, founded in 1986, is staffed by attorneys, other professional advocates, and a nurse. The Center's staff assists thousands of individuals in obtaining Medicare coverage and necessary health care each year. Armed with this experience, the Center works to obtain systemic change to eliminate unfair barriers to coverage and care. For decades, the Improvement Standard has been among the most significant obstacles facing the Center's clients, as well as the millions of other people with Medicare who have no legal representation. By removing this obstacle, we will open doors to needed medical and rehabilitative care for people with long term conditions and injuries. This is the goal of the proposed project.

Share a story! If you or someone you know has had problems obtaining Medicare coverage, necessary health care, or rehabilitative services because the patient was said to be chronic, stable, not likely to improve, or in need of "maintenance services only", share the story with us today.

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