Skilled maintenance services include outpatient physical therapy, occupational therapy, speech therapy, and long term home health care under Part B. Until recently, Medicare improperly denied payment for those services for some patients.
In 2012, a national class action lawsuit challenged Medicare’s use of an improper “improvement standard” to deny coverage to people who may not improve, but whose conditions may deteriorate without skilled maintenance services. The Vermont District Court approved the settlement of the case, Jimmo v. Sebelius, No. 5:11-cv-00017 (D.Vt.) on January 24, 2013.
Under the terms of the settlement agreement, the agency that administers Medicare (CMS) will revise its coverage standards to remove any reference to this improper standard and provide that Medicare coverage is available for the maintenance of chronic conditions. Attorneys from Vermont Legal Aid’s Medicare Advocacy Project served as co-counsel on the case with the Center for Medicare Advocacy.
The Settlement Agreement standards for Medicare coverage of skilled maintenance services apply now. Anyone who has been denied services for skilled maintenance based on the “improvement standard” since January 18, 2011 is encouraged to appeal the denial. More information about the lawsuit and the settlement is available at the Center For Medicare Advocacy.