News: Settlement could expand Medicare benefits
October 25, 2012
CDI Strategies - Volume 6, Issue 22
A recent proposed settlement agreement could expand Medicare benefits to the chronically ill and require updates to the Medicare Benefit Policy Manual, according to a release from The Center for Medicare Advocacy Inc., one of the co-councils in a Vermont-based lawsuit Jimmo v. Sebelius, No. 5:11-cv-00017 (D.Vt.)
Blind since adolescence, Vermont resident and now 76-year-old Glenda Jimmo requires consistent skilled nursing services in her home to help manage her multiple chronic conditions. Medicare denied payment for her services under a “decades-old practice that required many beneficiaries to show a likelihood of medical or functional improvement before Medicare would pay for skilled nursing and therapy services,” The New York Times reported.
According to the Times, the requirement to demonstrate improvement is not included in any Medicare law or regulation. However, because some Medicare manual provisions and Medicare contractor guidelines include restrictive standards and deny coverage in cases where patient care does not improve the patient’s health, such determinations frequently become the final decisions of the federal government.
Under the proposed settlement, “Medicare will pay for such services if they are needed to ‘maintain the patient’s current condition or prevent or slow further deterioration,’ regardless of whether the patient’s condition is expected to improve,” the Times reported.