Medicare Removes the “Improvement Standard”

My Life Care Planning Law Firms’ Association colleague Jerry Rothkoff, of the Rothkoff Law Group in Cherry Hill, NJ, recently reported the Center for Medicare and Medicaid Services (“CMS”) has agreed to settle the “Improvement Sandard” case of Jimmo vs. Sebelius. As a result, it is now clearly documented that “failure to improve” is not be the deciding factor in terminating an individual’s Medicare skilled nursing benefit.

Under the settlement agreement, the link for which is attached below, the Medicare policy manual will be revised to correct any suggestion that continued Medicare skilled nursing coverage is dependent on the beneficiary improving. Medicare will be required to pay for 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 Settlement also requires CMS to undertake an educational campaign to get the word out to providers, contractors, and adjudicators that they should not base coverage on the potential for improvement, but on the need for skilled care.

As a result of this settlement, Medicare beneficiaries with chronic conditions will find it easier to qualify for coverage for home care, skilled nursing home, and outpatient therapy. This will give millions of Americans who suffer from chronic and debilitating conditions a fair chance to obtain the Medicare coverage for which they qualify and the health care treatments they need to remain as healthy and productive as possible. Ending application of the Improvement Standard is a life or death issue for countless Americans

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