Improvement Standard Struck Down

Stethoscope-and-GavelFor over a dozen years, patients have been denied Medicare coverage because of the “improvement standard.” This was the illegal denial of coverage because a patient’s condition was stable, not improving, chronic and requiring only maintenance services. Jimmo v. Sebelius, No. 11-cv-17 (D.Vt.), filed January 18, 2011, was a lawsuit brought on behalf of six individual Medicare recipients and seven organizations representing persons with chronic conditions, to challenge this standard.

On October 16, 2012, the parties filed a settlement agreement with the federal court. On January 24, 2013, Chief Judge Christina Reiss approved the settlement agreement during the scheduled fairness hearing. With the settlement approved by the court, the Center for Medicare and Medicaid Services (“CMS”) is busy revising its Medicare Benefit Policy Manual and other guidelines and instructions to assure that patients needing skilled maintenance services in home health, nursing home and outpatient settings. CMS is to also develop an education program.

It is important to note that skilled maintenance services are available now, even though CMS is working on revising its rules and regulations and developing an education campaign. Any person denied coverage for maintenance services should immediately appeal such denial. For more information about the terms of the settlement and its implications, visit The Center for Medicare Advocacy. The Center for Medicare Advocacy has self-help materials for persons needing assistance with appeals.

Our office specializes in all areas of elder law, including advocacy. We have a geriatric Care Coordinator on staff to assist with assessments, care coordination and to assure a safe transition home or to an assisted living, RCFE or skilled nursing facility. You can learn more about our services at and The Riverside ElderCare Channel.

Dennis M. Sandoval, A Professional Law Corporation, of Riverside, California, provides representation throughout Riverside, Corona, Norco, Moreno Valley, Eastvale, Jurupa Valley, Mira Loma, Redlands, Ontario, Rancho Cucamonga, Upland, Chino, Chino Hills, San Bernardino, Fontana, Rialto, Colton, Perris, Hemet, Sun City, Temecula, Murrieta, Menifee, Winchester, San Jacinto, Lake Elsinore, Idyllwild, Lake Arrowhead, Crestline, Running Springs, Wrightwood, Yucaipa, Palm Springs and Palm Desert.

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