Medicare Change in Policy Will Benefit People with Disabilities

In late October, The U.S. Secretary of Health and Human Services and the Center for Medicare Advocacy announced a proposed settlement of a nationwide class-action lawsuit that is expected to significantly expand coverage of therapy and skilled nursing services for Medicare beneficiaries with chronic conditions or disabilities. The case, Jimmo v. Sebelius, challenged Medicare’s use of an “improvement standard” in determining medical necessity for skilled nursing services and outpatient therapy on the grounds that it violated Medicare law and deprived Medicare beneficiaries of needed care. That standard effectively denied coverage for skilled nursing facility (SNF) care, home health (HH) care, and outpatient therapy (OPT) services on the basis that an individual was not improving, without regard to the reasonableness and necessity of the care. In reaching an agreement, CMS would agree to revise its Medicare Benefits Policy Manual (MBPM) to clarify that maintenance is covered for skilled therapy services when an individualized assessment of the patient’s clinical condition demonstrates the need for a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration. Many Medicare beneficiaries with disabilities will benefit from this decision.

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