Medicare and Medicaid Services: No more “Improvement Standard”

For anyone with a chronic or long-term health issue, skilled care is often a must. Given that, a recent ruling that Medicare must continue to cover care even if a person isn’t likely to improve marks a victory.

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Prior to January’s Jimmo vs. Sebelius ruling, some Medicare providers used the so-called “Improvement Standard” to deny services to patients who were deemed unlikely to improve. Such patients were often red-flagged for payor audits, resulting in—at the very least—a delay in coverage for services, if not an eventual denial of services.

Long Awaited Verdict

The case was filed in 2012 on behalf of Glenda Jimmo, the lead plaintiff, and several other Medicare beneficiaries.

Jimmo lost a leg due to complications from diabetes and had received skilled nursing and in-home care that she believed was covered by Medicare. However, like many other patients in the last decade with stable or “plateaued” conditions, Jimmo’s medical status was reviewed, and it was determined that she didn’t meet the improvement standard.

The case brought to light the fact that despite numerous Medicare processors and auditors applying this rule of thumb to coverage decisions, the improvement standard doesn’t appear anywhere in Medicare policies or manuals.

As a result of the case, CMS has been required to do the following:

1. Revise policy manuals, guidelines, and health care provider instructions
2. Make clear that Medicare covers “skilled maintenance therapies” and nursing
3. Get rid of any contradictory CMS policies
4. Clearly explain the policy and guidelines to health care providers, workers, patients, caregivers, and others involved in care

In short, CMS now must make clear that they will provide ongoing maintenance services to individuals who demonstrate a need or a likelihood of deteriorating health without that care, regardless of whether those individuals are likely to be restored to full health.

Revising the Medicare Policy Manuals

As a result of the Jimmo decision, CMS published revised Medicare Policy Manuals on December 6, 2013.

According to the Center for Medicare Advocacy, CMS stated the following in regard to those revisions: “No ‘Improvement Standard’ is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes.”

In addition to revising the manuals, CMS is working to re-educate providers and auditors on the coverage guidelines.

Re-Review

Because numerous Medicare patients were denied coverage under the improvement standard, CMS established a re-review process for those claims.

According to CMS, patients who fall under “clarified maintenance coverage standards for the skilled nursing facility (SNF), home health (HH), and outpatient therapy (OPT) benefits, applicable when a patient has no restoration or improvement potential” may submit a form to have his or her claim considered anew.

Though that process is a lengthy five phases, it’s a step in the right direction toward ensuring that those in need get proper health care.

Whether for those who previously had coverage denied, or for those that may go into long-term or maintenance care in the coming years, the Jimmo case may quell some fears about losing coverage in the case of a debilitating condition.

This case is significant not only for those patients who are in nursing homes.   Medicare contractors and private insurers have been applying the “Improvement Standard” as justification to deny benefits for many patients. 

Yet patients suffering chronic diseases and who need continuous treatment to avoid further deterioration should not be denied care because the care does not result in improvement in their health status. For many patients, maintaining their current health status is as important as improvement is for others.

Hopefully, this case will bring more careful consideration to the needs of patients whose only hope is to retain their current level of health status, and not risk further deterioration simply because their status shows no improvement.

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