On November 20, the Center for Medicare Advocacy, with support from the John A. Hartford Foundation, convened an online gathering of members of the Jimmo Implementation Council and other stakeholders in the effort to remove barriers to care for people with longer-term, chronic, and debilitating conditions. The Council first met in 2015 in Washington, DC … Read more

[Date] [Attorney’s Name] [Address] Re: [Beneficiary’s Name], Medicare No. [XXXXX] To Whom It May Concern: I am writing on behalf of my client, [Full Name], to request an expedited reconsideration. The skilled nursing facility (SNF) terminated Mr./Ms. [Last Name]’s Medicare coverage on [Date]. The SNF told Mr./Ms. [Last Name] that his/her Medicare coverage was ending … Read more

Background The United States District Court for the District of Vermont approved a settlement agreement in Jimmo v. Sebelius[1] on January 23, 2013. The Jimmo Settlement required the Centers for Medicare & Medicaid Services (CMS) to confirm that Medicare coverage of skilled nursing facility, home health, and outpatient therapy services must be determined on the … Read more

Medicare coverage of skilled nursing and/or therapy services depends on a beneficiary’s need for the skilled care, not on the individual’s potential for improvement. The Settlement Agreement in Jimmo v. Sebelius, approved by a federal district court in 2013, required the Centers for Medicare & Medicaid Services (CMS) to confirm that coverage of skilled nursing … Read more

With support from The John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Fact Sheet to help Medicare providers, contractors, and adjudicators apply the correct legal standard to Medicare coverage and payment determinations – as required by the Jimmo v. Sebelius Settlement Agreement. The Jimmo Settlement means that Medicare coverage and … Read more

Despite the Jimmo case’s confirmation that Medicare coverage of a stay in a skilled nursing facility (SNF) is appropriate to maintain a resident’s functional status, when the nursing or therapy services must be provided by a professional nurse or therapist, SNFs and managed care plans frequently continue to deny medically necessary coverage.  Expedited appeals to … Read more

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Checklist to help Medicare beneficiaries and their families respond to unfair Medicare denials for skilled nursing facility care based on an erroneous “Improvement Standard.” The Checklist outlines the coverage criteria for SNF care and emphasizes language from the Jimmo Settlement … Read more

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Checklist to help Medicare beneficiaries and their families respond to unfair Medicare denials for home health care based on an erroneous “Improvement Standard.” The Checklist outlines the coverage criteria for home health care and emphasizes language from the … Read more

With support from The John A. Hartford Foundation, the Center for Medicare Advocacy has produced two new Checklists to help Medicare beneficiaries and their families respond to unfair Medicare denials based on an erroneous “Improvement Standard.” Per the Jimmo Settlement, CMS revised the Medicare Benefit Policy Manual to clearly disavow any notion that residents of … Read more

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy provides the following Fact Sheet to help Medicare home health beneficiaries and their families respond to unfair Medicare denials based on an erroneous “Improvement Standard.” The Fact Sheet emphasizes language from the Jimmo Settlement Agreement, wherein the Centers for Medicare & Medicaid … Read more

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy provides the following Fact Sheet to help Medicare nursing home beneficiaries and their families respond to unfair Medicare denials based on an erroneous “Improvement Standard.” The Fact Sheet emphasizes language from the Jimmo Settlement Agreement, wherein the Centers for Medicare & Medicaid … Read more

A young man who suffered a traumatic brain injury (TBI) following a fall in 2008 was receiving outpatient physical therapy three times a week.  While his therapy was originally covered by his Medicare Advantage (MA) plan, the plan denied further coverage of his therapy, contending that the recovery period for TBI had passed and that … Read more

Jimmo v. Sebelius, No. 11-cv-17 (D. VT), 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 that they were not improving or did not demonstrate a potential for improvement (known as … Read more

Toolkit: Medicare Home Health Coverage & <i>Jimmo v. Sebelius</i>

Jimmo v. Sebelius, No. 11-cv-17 (D. VT), 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 that they were not improving or did not demonstrate a potential for improvement (known as … Read more

On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law by the President. The budget act includes a “health extenders” package that, among other changes, permanently repeals annual Medicare payment limits (or caps) on outpatient physical, speech, and occupational therapy services.[1] Pursuant to the Balanced Budget Act of 1997, Medicare Part … Read more

Jimmo v. Sebelius, No. 11-cv-17 (D. VT), 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 that they were not improving or did not demonstrate a potential for improvement (known as … Read more

Based on recent experience, the Center for Medicare Advocacy provides this Practice Tip for providers and advocates for patients who need to change from an improvement mode to maintenance mode for nursing or therapy. The Center is seeing decisions from Medicare Contractors requiring that providers obtain new orders when a patient’s goals change to maintenance … Read more