Settlement on Improvement Standard Finalized: Briefing for Full Membership February 20
Monday, February 4, 2013
by: VNAA Policy Team

Section: Public Policy and Advocacy

Gill Deford, Director of Litigation at the Center for Medicare Advocacy and the lead attorney on the legal settlement on the Improvement Standard, briefed the VNAA’s Public Policy Council on January 22. A teleconference briefing for the full membership will be held on February 20, from 1:00-2:00 p.m. ET (10:00-11:00 a.m. PT) to register click here.

At the Public Policy Council meeting, Attorney Deford provided background on the Improvement Standard and referenced the Center for Medicare Advocacy Website which states:  

“It is important to note that the Settlement Agreement standards for Medicare coverage of skilled maintenance services apply now – while CMS works on policy revisions and its education campaign. The Center is hearing from beneficiaries who are still being denied Medicare coverage based on an Improvement Standard, but coverage should be available now for people who need skilled maintenance care and meet any other qualifying Medicare criteria. This is the law of the land – agreed to by the federal government and approved by the federal judge.  We encourage people to appeal should they be denied Medicare for skilled maintenance nursing or therapy because they are not improving.” 

The settlement, finalized on January 24, 2013, was the result of a lawsuit, Jimmo v. Sebelius, brought by several patients and seven national organizations representing people with such chronic conditions such as Multiple Sclerosis, Alzheimer's disease, ALS, Parkinson's disease and paralysis. One important fact is that the settlement agreement is retroactive to January 18, 2011.

Under the order, the Centers for Medicare and Medicaid Services (CMS) is required to:

  1. Revise its Medicare Benefit Policy Manual along with other policies and guidelines;
  2. Conduct an educational campaign on the policy revisions; and
  3. Establish a re-review policy for patients denied services who had a live claim in the administrative process on or after January 18, 2011.

It is expected that the CMS manual will be updated within the next six months. VNAA plans to advocate on behalf of its members throughout these processes.

The agreement also establishes a process called "re-review" for Medicare beneficiaries who received a denial of skilled nursing facility care, home health care, or out-patient therapy services (physical therapy, occupational therapy, or speech therapy) because of the Improvement Standard as of January 18, 2011. When the government completes revision of its policy and guidelines, and educates Medicare decision-makers, individuals will be able to get a re-review of denied claims.
The Center for Medicare Advocacy has posted a copy of the settlement as well as a listing of Frequently Asked Questions on their Website. To review click here.
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