The Medicare Improvement Standard Case reaches settlement

It has been a long standing practice, among skilled nursing facilities, home health providers, and outpatient therapy, that when a patient failed to show progress to discontinue skilled services despite continuing to need therapy or skilled nursing to maintain the person’s condition or prevent deterioration. This unwritten “rule of thumb” was challenged last year in a Federal class action law suit, Jimmo v. Sebelius, on behalf of Medicare beneficiaries who have been denied necessary care based on the improvement standard.
Recently attorney’s have agreed to a settlement in this so called “improvement standard” case. On December 10, 2012 a Notice of Settlement will begin to be distributed outlining terms of the settlement. The final order is not expected until sometime early next year. From the final order Medicare Manuals will eventually be revised removing any suggestion that benefits are conditioned upon “improving”. However, there is no need for health care providers to wait for written revisions but should begin implementing the maintenance standard now.
Even with the full implementation of this policy clarification Medicare is still a limited payor for inpatient long term care, providing a maximum of only 100 days of coverage per benefit period. Additionally this policy clarification will not alter the requirement that the services provided must be considered “skilled services”. However, this still has enormous positive implications for elders and disabled individuals receiving Medicare skilled services and is expected to aid in agency’s key initiative of reducing hospitalizations and re-hospitalizations.
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