‘Improve or You’re Out’ Medicare Policy Unchanged

Glenda Jimmo has been blind since childhood because of problems related to her diabetes. A few years ago she had her leg amputated below the knee and all but one toe removed from the remaining leg. After the surgery she received rehab services from a local home care agency, paid for by Medicare– but then the payment stopped.  Medicare refused to pay for her care based on the eligibility rule concerning patient status improvement.   Three years ago she successfully sued Medicare over the claim denial, and although she won the court challenge, nothing has changed.  Nothing.  Medicare still won’t pay.

According to a recent article in Vermont Today and the Rutland Herald, the Vermont woman who led a national class-action lawsuit to have her in-home treatment covered by Medicare is headed back to federal court.

Glenda Jimmo and husband Dennis at their home in Lincoln, VT, photo by Andrew Stein

Glenda Jimmo and husband Dennis at their home in Lincoln, VT, photo by Andrew Stein

In January 2011, the Center for Medicare Advocacy and Vermont Legal Aid filed a class action lawsuit, Jimmo v. Sebelius, against the Obama administration in federal court aimed at ending the government’s use of the improvement standard. After the court refused the government’s request to dismiss the case, and the administration lost in similar individual cases in Pennsylvania and Vermont, it decided to settle.

As part of the proposed settlement, Medicare was to revise its manual that contractors follow to clarify that Medicare coverage of skilled nursing and therapy services “does not turn on the presence or absence of an individual’s potential for improvement” but rather depends on whether or not the beneficiary needs skilled care, even if it would simply maintain the beneficiary’s current condition or slow further deterioration.

The New York Times article at the time quoted a trustee of the Medicare program that although the change could cost Medicare more money, it could also save some money because physical therapy and home health care may help keep beneficiaries out of more expensive institutions like nursing homes and hospitals.

Despite receiving a policy-changing settlement from the federal government, and telling her story in national media in an effort to expand coverage for Medicare patients across the country, Glenda Jimmo’s attorneys say she is still not receiving Medicare coverage. Vermont Legal Aid attorney Michael Benvenuto filed a new lawsuit in the Rutland Court two weeks ago.

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