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

Medicare coverage of nursing home care depends on a resident’s need for skilled nursing and/or therapy, not the resident’s potential for improvement. However, too many nursing home residents continue to be denied skilled services on the basis of an “Improvement Standard,” which was firmly rejected by the court-approved settlement in Jimmo v. Sebelius. In order … 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

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 … 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

In 2013, a federal district court approved a settlement agreement in Jimmo v. Sebelius, No. 5:11-CV-17 (D. VT). The Jimmo Settlement confirmed that Medicare coverage should be determined based on a beneficiary’s need for skilled care (nursing or therapy), not on the individual’s potential for improvement. The Jimmo Settlement and court decisions pertain to all … Read more

The National Association of Insurance Commissioners (NAIC) is a standard-setting and regulatory support organization governed by chief insurance regulators from across the country. NAIC’s website indicates that organizational members and its resources, “form the national system of state-based insurance regulation in the U.S.” One such resource is NAIC’s Glossary of Health Insurance and Medical Terms, … Read more

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Fact Sheet to help Medicare beneficiaries and their families respond to unfair Medicare denials for care at inpatient rehabilitation hospitals/facilities (IRH/F). The Fact Sheet outlines the coverage criteria for IRH/Fs and emphasizes language from the Jimmo Settlement Agreement. … Read more

The Settlement Agreement in Jimmo v. Sebelius, No. 5:11-CV-17 (D. VT), was approved by a federal district court in January 2013. The Centers for Medicare & Medicaid Services (CMS) was required to confirm that Medicare coverage is determined by a beneficiary’s need for skilled care and is not based on a beneficiary’s potential for improvement. … 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

The Center for Medicare Advocacy recently completed a survey of Jimmo v. Sebelius stakeholders to analyze the effectiveness of the Centers for Medicare & Medicaid Services’ education efforts regarding the Jimmo Settlement, which clarified that Medicare must cover skilled maintenance care in the home health, skilled nursing facility and outpatient therapy settings. Unfortunately, the results … 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

The Plan: Pass a Devastating Tax Bill, Balloon the Deficit, then Gut the Social Programs We Rely On Jimmo Update: Court Orders CMS to Modify Special Jimmo Webpage ACA and Medicare Enrollment Periods End Soon Changes to Notice of Qualified Medicare Beneficiary (QMB) Status The Plan: Pass a Devastating Tax Bill, Balloon the Deficit, then … Read more

CMA Alert –  OIG Warns of Abuse in SNFs; Ted Kennedy, Jr. Joins CMA Advisory Board; “Jimmo” Corrective Action Plan

HHS OIG Warns of Potential Elder Abuse in Skilled Nursing Facilities Connecticut State Senator Ted Kennedy, Jr. Joins Center for Medicare Advocacy Advisory Board Jimmo Corrective Action Plan Completed HHS OIG Warns of Potential Elder Abuse in Skilled Nursing Facilities Last week, the HHS Office of Inspector General (OIG) issued an Early Alert, warning of … Read more

Jimmo Corrective Action Plan Completed CMS Adds Resources Regarding Medicare Coverage To Help People Who Need Skilled Maintenance Nursing or Therapy As ordered by the federal judge in Jimmo v. Sebelius, the Centers for Medicare and Medicaid Services (CMS) published a new webpage containing important information about the Jimmo Settlement on its CMS.gov website. The … Read more

On February 16, 2017, the Jimmo v. Sebelius court approved a Corrective Statement to be used by the Centers for Medicare and Medicaid Services (CMS) to affirmatively disavow the use of an “Improvement Standard” for Medicare coverage.  The government will use the statement as part of its Corrective Action Plan, which was ordered by the … Read more

In a decision released February 2, 2017, the federal judge overseeing the Settlement Agreement in the Medicare “Improvement Standard” case (Jimmo v. Burwell) ordered the Secretary of Health & Human Services to carry out a Corrective Action Plan to remedy the Department’s noncompliance with the Settlement.  In August, 2016, Chief Judge Christina Reiss, of the … Read more

No. 11-cv-17 (D.Vt.), filed January 18, 2011 Issue: Whether the "Improvement Standard", which operates as a rule of thumb to terminate or deny Medicare coverage to beneficiaries who are not improving, violates substantive and procedural requirements of the Medicare statute, the Administrative Procedure Act, and the Freedom of Information Act, and the Due Process Clause of … Read more

For Immediate Release Contact: Matthew Shepard, mshepard@medicareadvocacy.org or 860-456-7790. Aug. 18, 2016. Burlington, Vt.  In an Opinion and Order filed late yesterday and released this morning, Chief Judge Christina Reiss, who oversees the “Improvement Standard” case (Jimmo v. Burwell, No. 11-cv-17 (D.Vt.)), ordered the federal government, through its Centers for Medicare & Medicaid Services (CMS), … Read more

Beneficiaries Across the Country Still Denied Needed Coverage Due to Illegal Use of Improvement Standard March 1, 2016 – Today, Plaintiffs’ counsel, the Center for Medicare Advocacy and Vermont Legal Aid, filed a Motion for Resolution of Non-Compliance with the Settlement Agreement in the landmark case, Jimmo v. Sebelius. The filing comes after three years … 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

With support from the John A. Hartford Foundation, the Center for Medicare Advocacy has created a council of beneficiary advocates, providers, policy-makers and other partners to discuss, analyze and advance the implementation of the Jimmo v. Sebelius "Improvement Standard" Settlement. The Center convened the first meeting of the multi-disciplinary Council on June 23, 2015 at … Read more

If you are covered by Medicare and you have a long-term or chronic condition, you may be eligible to have Medicare re-review your claims that were denied in prior years.  Please read carefully. In addition to revising Medicare manual provisions to now allow Medicare coverage for skilled maintenance care, the Settlement Agreement in Jimmo v. … Read more

January 24, 2014 – Today marks the one-year anniversary of the landmark Jimmo v. Sebelius settlement.  The Jimmo case was brought in 2011 by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of a nationwide class of Medicare beneficiaries who were denied Medicare coverage and access to necessary health care or therapy … Read more

As of December 6, 2013, Centers for Medicare & Medicaid Services (CMS) Policy manuals have been updated to reflect the settlement in Jimmo vs. Sebelius, No.11-cv-17 (D.VT, January 24, 2013).  The manuals now make it clear that improvement is not necessary for coverage of skilled nursing and therapy services. For example, the home health section … Read more

December 9, 2013 – The Center for Medicare Advocacy is pleased to announce that the Medicare Policy Manuals have been revised pursuant to the Jimmo vs. Sebelius Settlement. The Manual revisions, which clarify that improvement is not required to obtain Medicare coverage, were published by the Centers for Medicare & Medicaid Services (CMS) on Friday … Read more

  Attorneys from the Center for Medicare Advocacy, Vermont Legal Aid and the Centers for Medicare & Medicaid Services (CMS) have agreed to settle the "Improvement Standard" case, Jimmo v. Sebelius, No. 11-cv-17 (D.VT), filed January 18, 2011.  A proposed settlement agreement was filed in federal District Court on October 16, 2012.  When the judge approves … Read more

(print stories only) Mrs. Jimmo Lead plaintiff in the Improvement Standard case, Glenda Jimmo of Bristol, Vermont is blind and has had her right leg amputated due to complications from diabetes. She requires a wheelchair, and receives multiple home health care visits per week for various treatments for her complex condition. However, Medicare denied coverage … Read more

General Question: Are professional therapy services available under Medicare only for patients who are improving or who are expected to improve? Answer: No. The Jimmo Settlement confirms that services by a physical therapist, occupational therapist, and speech and language pathologist are covered by Medicare, Parts A and B, and by Medicare Advantage Plans in skilled … Read more

Introduction Checklist for Home Health Appeals Quick Screen: Should My Home Health Care Be Covered By Medicare? Home Health Appeal Details Additional Information The “Improvement Standard” Myth and Home Health Care Glossary of Terms Federal Regulations – Home Health Coverage Federal Regulations – Expedited Appeals Centers for Medicare & Medicaid Services (CMS) Home Health Manual Provisions … Read more

Based on an article by Judith A. Stein, Executive Director, Center for Medicare Advocacy, Copyright © 2013 Bloomberg BNA (2/2013). Mrs. “P” was 68 years old and living with Amyotrophic Lateral Sclerosis (ALS, commonly known as Lou Gehrig's disease) when she contacted the Center for Medicare Advocacy. She needed a wheelchair, was unable to stand … Read more

Completion of legal process for beneficiaries with long-term and chronic conditions  January 24, 2013 – Mansfield, Conn. – The Center for Medicare Advocacy, along with its co-counsel Vermont Legal Aid are pleased that the Settlement Agreement in the Medicare Improvement Standard case, Jimmo v. Sebelius, was approved today at the conclusion of a scheduled fairness … Read more

January 16, 2013 – Mansfield, Ct. – The Center for Medicare Advocacy, along with its co-counsel Vermont Legal Aid and the law firm of Wilson Sonsini Goodrich & Rosati, marks a critical next step toward finalizing its class action lawsuit against the federal government this week. With the recent close to the comment period for … Read more

One of the deficit reduction proposals being discussed to achieve savings from Medicare is to introduce new cost-sharing for home health care. As a means to ward off such potential home health co-payments, some instead suggest capping Medicare payment for episodes of care, effectively limiting the duration of time individuals could access home health services. … Read more

In October 2012, the Center for Medicare Advocacy announced the settlement of the “Improvement Standard” class action lawsuit, Jimmo vs. Sebelius. For more than thirty years, the wrongful interpretation of the Medicare statue led to the illegal denial of Medicare coverage and health care for tens of thousands of Medicare beneficiaries on the grounds that … Read more

Medicare: Just the Facts! Misinformation about Medicare and the Affordable Care Act is widespread and increasing as the election nears.  Below, we try to dispel misinformation and base discussions on a factual foundation.  Spread the word. Help set the record straight! The Fact Here's Why The Affordable Care Act does NOT cut Medicare for beneficiaries. … Read more

Attorneys from the Center for Medicare Advocacy, Vermont Legal Aid and the Centers for Medicare & Medicaid Services (CMS) have agreed to settle the "Improvement Standard" case, Jimmo v. Sebelius.[1] A proposed settlement agreement[2] was filed in federal District Court on October 16, 2012.  When the judge approves the proposed agreement, a process that may … Read more

Plaintiffs in a lawsuit filed by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of Medicare beneficiaries with long-term and chronic conditions have overcome a major hurdle.  In a comprehensive 35-page decision, a federal judge in Vermont refused the federal government's request to throw out a lawsuit that seeks to end use … Read more

  March 3, 2011 For Immediate Release Contact:  Gill Deford, (860) 456-7790 gdeford@medicareadvocacy.org Judith Stein, (860) 456-7790 jstein@medicareadvocacy.org Today, the Alzheimer's Association and United Cerebral Palsy joined five other national organizations and several Medicare beneficiaries in a class action lawsuit challenging the Medicare program's Improvement Standard.  Under that Standard, Medicare patients suffering from chronic conditions … Read more