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The Centers for Medicare & Medicaid Services (CMS) launched a “Patients over Paperwork” initiative in 2017 “to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience.”[1] Unfortunately, most of CMS’s efforts under this initiative focus on reducing so-called provider “burden” instead of improving beneficiary experience. As a result, Medicare beneficiaries and their families continue to experience the greatest possible burden: unnecessary and unlawful barriers to care. For example, the Center for Medicare Advocacy (the Center) still regularly hears from beneficiaries and families about the denial of Medicare-covered skilled care in home health, outpatient therapy, and skilled nursing facilities solely because the beneficiary is not improving. These denials violate the settlement agreement in Jimmo v. Sebelius.[2]

The Jimmo Settlement, approved by a federal district court in 2013, confirmed that Medicare coverage should be determined based on a beneficiary’s need for skilled care (nursing or therapy), not on the potential for improvement. Relevant chapters of the Medicare Benefit Policy Manual now clearly state that “[s]killed care may be necessary to improve a patient’s condition, to maintain a patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.”[3] Sadly, more than six years after the Settlement’s approval, the ongoing lack of knowledge about Jimmo continues to harm beneficiaries in both traditional Medicare and Medicare Advantage.

CMS could dramatically reduce beneficiary burden by insisting that the Jimmo Settlement is fully implemented. This would ensure people living with longer-term, chronic, and debilitating conditions can obtain, and retain, necessary care to maintain their conditions or slow deterioration. The barriers such patients and their families currently face are unjust and often unsustainable. While CMS recently spotlighted the Jimmo Settlement on its “Skilled Nursing Facility Center” webpage, the Center urges more assertive action. CMS should provide more extensive education about Jimmo to providers, contractors, and adjudicators. It should actively monitor these entities and ensure Jimmo is implemented.

Our 2018 national survey of Medicare providers found that a shocking 40 percent of respondents had never even heard about the Settlement. 30 percent were not aware that Medicare coverage does not depend on the beneficiary’s potential for improvement. Given that beneficiaries and families affected by such unlawful Medicare denials may have to go through multiple levels of appeal and/or forego care, improving beneficiary experience by addressing Jimmo implementation problems would truly put patients over paperwork.

August 22, 2019 – D. Valanejad

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[1] What is Patients over Paperwork, CMS, https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/PatientsOverPaperwork.html (last visited Aug. 21, 2019).
[2] No. 5:11-CV-17 (D. VT).
[3] CMS Transmittal 179, Pub 100-02, 1/14/2014; see also Medicare Benefit Policy Manual (MBPM), Chapter 7 – Home Health Services, Sections 20.1.2, 40.1-40.2; MBPM, Chapter 8 – Coverage of Extended Care (SNF) Services Under Hospital Insurance, Sections 30.2 30.4; MBPM, Chapter 15 – Covered Medical and Other Health Services, Sections 220, 220.2-220.3, 230.1.2.

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